
GnHd 


U. S. DEPARTMENT OF LABOR 

JAMES J. DAVIS, Secretary 

CBN BRNCh . BUREAU OF LABOR STATISTICS 

ETHELBERT STEWART, Commissioner 


GenColl 


BULLETIN OF THE UNITED STATES 1 \T^ 11 0 

BUREAU OF LABOR STATISTICS/. lNO. 


WORKMEN’S INSURANCE AND COMPENSATION SERIES 


NATIONAL HEALTH INSURANCE 
IN GREAT BRITAIN, 1911 TO 1921 


By HENRY J. HARRIS 



APRIL, 1923 



WASHINGTON 


GOVERNMENT PRINTING OFFICE 

. 

1923 



































Glass. H& qsqq 

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U. S. DEPARTMENT OF LABOR 

JAMES J. DAVIS, Secretary 


IZ33 


BUREAU OF LABOR STATISTICS 

ETHELBERT STEWART, Commissioner 


BULLETIN OF THE UNITED STATES 1 
BUREAU OF LABOR STATISTICS] 

f.1 

N 

lo. 312 

WORKMEN'S INSURANCE AND COMPENSATION 

SERIES 


NATIONAL HEALTH INSURANCE 
IN GREAT BRITAIN, 1911 TO 1921 

By HENRY J. HARRIS 

i* 



APRIL, 1923 


WASHINGTON 

GOVERNMENT PRINTING OFFICE 
1923 

























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LIBRARY Of COrtQRiESS 
ReCEJVED 

JUN 22 1923 


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CONTENTS, 


Page. 

Introduction. 1-4 

Summary statement of the system. 4-12 

Persons included.12-14 

Compulsory insurance.12,13 

Voluntary insurance. 13,14 

Deposit contributors. 14 

Dependents of insured persons. 14 

Persons granted exemption from compulsory insurance. 14 

Industries and employments included. 14,15 

Disability provided for.15,16 

Benefits.16-35 

Medical benefit. 16-20 

Qualifications. 16 

General arrangements for medical service. 16,17 

Allocation. 17,18 

Drugs and appliances. 18,19 

Kind of treatment provided. 19 

Certification.19,20 

Sanatorium benefit.20-24 

Prior to 1921. 20,21 

After 1921.21-23 

Finances of the sanatorium benefit.23,24 

Sickness benefit.24-28 

Qualifications.24,25 

Rates of benefit...25,26 

Benefits while in arrears of contribution.26, 27 

Behavior during sickness.27, 28 

Disablement benefit.. 29 

Qualifications. 29 

Rate of benefit. 29 

Maternity benefit.29-32 

General features.29,30 

Waiting (or probationary) period and other qualifications.30,31 

Rate of benefit.31,32 

Additional benefits.32, 33 

• Miscellaneous benefit features.33-35 

Mercantile marine. 33 

Married women. 34 

The “free year’s” benefit....... 34 

Inmates of institutions. 34, 35 

Sources of income.35-38 

Government grants. 35 

Contributions.36, 37 

Ordinary rate. 36 

Low-wage earners. 36 

Weekly rates for low-wage earners prior to July 5, 1920. 36 

Mercantile marine. 37 

Special groups. 37 

Arrears.37,38 

Financial administration. 38-53 

Actuarial basis of the system. 38-40 

Reserve values.40, 41 

The contingencies fund.41,42 

The central fund.42,43 

The women’s equalization fund.43,44 

The value of the benefits.44-46 

Reserve suspense fund. 46 

The actuarial valuation.46-53 

Disposition of the surplus. 52 

Amount of additional benefits. 52 

Deficiencies^. 53 


iii 

































































IV 


CONTENTS. 


Page. 

General administration. 53-63 

Ministry of Health.54,55 

National health insurance joint committee. 55 

Consultative councils.55,56 

Insurance committees. t .56-58 

Income of committees.57,58 

Approved societies.58-61 

Membership..59,60 

Types of societies. 60,61 

Transfers between societies. 61 

Associations of societies.61, 62 

The deposit contributors’ fund. 62 

Excessive sickness. 63 

Operations of the system.63-95 

Sources of information.63, 64 

Number of persons insured.64, 65 

Expenditure for pecuniary benefits.65-68 

Sanatorium benefit.68-74 

Financial operations. 74-88 

Summary of receipts and expenditures.74-76 

Reserves on March 31,1920. 76 

Income in 1920. 77, 78 

National health insurance fund.78-81 

Ministry of Health.81, 82 

Staff of insurance department.82, 83 

National health insurance joint committee. 83 

Receipts and expenditures of approved societies. 84-86 

Receipts and expenditures of insurance committees.87,88 

Statistics of sickness. 88,89 

Operations of typical individual carriers.89-95 

Friendly societies.89-91 

Establishment fund...91, 92 

Industrial assurance society.93-95 

Association of small societies. 95 

Bibliography on national health insurance in Great Britain.96-103 





































BULLETIN OF THE 

U. S. BUREAU OF LABOR STATISTICS 


no. 312 WASHINGTON april, 1923 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN, 
1911 TO 1921. 

INTRODUCTION. 

Great Britain placed in operation a compulsory system of health 
and invalidity insurance in the year 1912, when the act of December 
16, 1911, came into force. This sharp break with the traditional 
policy of the Government of that country was made, according to 
one critic, with dramatic suddenness, though also “with almost uni¬ 
versal consent.” 

The reasons for the introduction of the system came out fully in 
the debates in Parliament on the bill. Emphasis was placed on the 
fact that sickness was the cause of poverty to a large extent; a promi¬ 
nent Government official had said that 30 per cent of the pauperism 
was due to sickness; that pauperism was a serious problem had been 
demonstrated by the old age pension law of 1906. This act had 
revealed a mass of destitution and suffering in the age period 70 years 
and over, and the same condition undoubtedly existed for the ages 
prior to 70. 

Considerable provision had already been made against distress 
due to death, sickness, and unemployment. There was hardly a 
household in the country where there was not some form of insurance 
against death, which had always been one of the main activities of 
the mutual and commercial organizations for providing insurance. 
The plan for State insurance, therefore, omitted any burial benefits. 
There was also a widespread system of provision against distress 
due to sickness by the voluntary organizations; there were perhaps 
between six and seven million persons who had secured such pro¬ 
vision, but most of it was inadequate, and, worst of all, it was fre¬ 
quently allowed to lapse, mostly for reasons beyond the control of the 
wage earner. In very many cases the purchase of such insurance 
was beyond the means of the wage earner, and in 1911 it was esti¬ 
mated that only about one-half of them were in possession of such 
protection. 

It was estimated at the time that there would be about 9,200,000 
men and 3,900,000 women who would be subject to the health in¬ 
surance system. The actual experience later showed that these 
estimates were approximately correct, as the number of men insured 
in 1914 was about 9,680,000 and the number of women was about 
4,077,000, or a total of about 13,757,000. As shown in the table 
following, the number of occupied persons over 10 years of age in 
England and Wales in 1911 was about 16,300,000; since 85 per cent 

1 




2 


NATIONAL HEALTH INSURANCE IN CLEAT BRITAIN 


of the insured population is resident in these two countries, a com¬ 
parison of the occupied with the insured population will give a fair 
idea of the extent of the insurance. The number of insured persons 
in England and Wales in 1913 was about 11,211,000; this number is 
about 70 per cent of the persons engaged in occupations in 1911. 

At the time the insurance bill was placed before Parliament the 
total population of England and Wales was 45,221,615; the number 
of persons 10 years of age or over who were reported by the 1911 
census as having an occupation was 16,286,919. The following 
table shows the data for 1911 and the three preceding censuses: 

NUMBER OF OCCUPIED AND OF UNOCCUPIED PERSONS 10 YEARS OF AGE AND OVER 
IN ENGLAND AND WALES AND PROPORTION IN EACH CLASS, 1881, 1891, 1901, AND 1911. 

[Source: Census of England and Wales, 1911. Vol. X, Part 1, London, 1914. Cd. 7018. Pp. 552, 553; 
Statistical abstract for the United Kingdom, 65th number. London, 1919. Cmd. 491. P. 383.] 


Year. 

Total occupied 
and 

unoccupied. 

Retired or 
unoccupied. 

Engaged in 
occupations. 

Total 

population of 
United King¬ 
dom. 

Number: 

1881. 

1891. 

1901. 

1911. 

Proportion per million of population 10 
years of age and over: 

1881. 

19,306,179 
22,053,857 
25,323,844 
28,519,313 

1, 000,000 
1,000,000 
1,000,000 
1,000,000 

8,144,463 
9,301,862 
10,995,117 
12,232,394 

421,858 
421,779 
434,180 
428,916 

11,161,716 
12,751,995 
14,328,727 
16,286,919 

578,142 
578,221 
565,820 
571,084 

34,884,848 
37,732,922 
41,458,721 
45,221,615 

1891.^. 


1901.7*. 


1911. 





According to these returns, about 57 per cent of the population 10 
years of age and over were gainfully employed at the time the re¬ 
spective census figures were collected, the proportion showing a 
slight decrease in the last two censuses as compared with the earlier 
censuses. 

The principal occupations in which these persons in the gainfully 
employed population were engaged in 1911 were the following: 


PRINCIPAL OCCUPATIONS, ENGLAND AND WALES, 1911. 

[Source: Census of England and Wales, 1911, Vol. X, Occupations and Industries. Part I, London, 1914. 

Cd. 7018. P.cl.) 


Industry or service. 

Net total in industry or 
service. 

Number classified in occupa¬ 
tion census. 

Males. 

Females. 

Total. 

Males. 

Females. 

Total. 

Domestic indoor service. 

41,765 

1,260,673 

1,302, 438 

54,260 

1,335,358 

1,389,618 

Agriculture (on farms, woods, and gardens) 

1,134,714 

94,841 

1,229,555 

1,140,515 

94,722 

1,235,237 

Coal mining. 

968,051 

3,185 

971,236 

884, 530 

2,856 

887,386 

Building. 

814, 989 

2, 953 

817,942 

872, 963 

572 

873, 535 

Cotton manufacture. 

Local government (including police and 

poor-law services). 

Railway companies’ service. 

Engineering and machine making, iron 

250,991 

372,834 

623, 825 

233,380 

371,797 

605; 177 

412,501 

176,450 

588,951 

107,810 

19,437 

127,247 

535,799 

7,170 

542,969 

397,990 

2,636 

400,626 

founding and boiler making. 

502,942 

7,284 

510,226 

516,353 

4,571 

520,924 

Dressmaking. 

3,826 

333,129 

336, 955 

2, 815 

339, 240 

342; 055 

Teaching. 

89, 648 

211,183 

300, 831 

76, 428 

187, 283 

263;711 

Inn, hotel service. 

178, 550 

110, 506 

289,056 

156,389 

89, 497 

245,886 

Grocery. 

210,387 

58,935 

269,322 

165, 981 

53, 638 

219,619 

Tailoring. 

127,301 

127, 527 
87,609 

254,828 

122,352 

127,115 

249, 467 

Printing, bookbinding, and stationery.... 
National Government. 

161, 856 

249,465 

155,170 

89, 680 

244, 850 

215,110 

34, 089 

249,199 

140,814 

31,538 

172; 352 

Woolen and worsted manufacture. 

105, 552 

127, 637 

233,189 

95,531 

127,148 

222,679 

Boot, shoe, etc., making. 

172, 000 

45, 986 

217,986 

169,171 

44; 523 

213, 694 

Drapery... 

93,171 

110,955 

204,126 

66,362 

84, 606 

150,968 




























































Introduction. 


3 


The foregoing table shows, first, the total number of persons 
employed in each of the industries having more than 200,000 persons 
employed in them and, second, the number for which occupational 
details were reported. 

These data show that the country has a wide variety of industries, 
including agriculture, mining, construction, manufacturing, and com¬ 
merce, and also that the professions, such as teaching, are well repre¬ 
sented. 

One problem in providing a system of health insurance for this 
population was to decide whether it should be organized by industries 
or by other groups. The German plan was to use the industry as a 
principal basis of organization, but as early as 1908 the leader of the 
Government had said in the House of Commons that the German 
plan was unsuited to British needs; by disregarding the occupational 
or industrial lines it was believed tnat a solution could be found 
which would appeal more strongly to the traditional individualism of 
the British wage earners. 

The plan adopted made use of a wide variety of existing voluntary 
organizations as carriers, some of which were based on occupational 
lines, but the greater part consisted of a membership selected without 
regard to industry or occupation. 

These societies had used a contributory system of insurance, and 
this helped to make the operation of the system easier, as the ma¬ 
chinery of collecting contributions was already in existence or 
familiar to most of the persons to be insured. During the discussions 
on the bill the suggestion was made that the State should bear the 
entire cost of the insurance, as was the case with the old-age pension 
system. It was easy to prove that the amount necessary to cover 
the cost of such a plan was so heavy that the question practically 
resolved itself into deciding in favor of a contributory system or 
of having "no State insurance at all. 

From the very start it was recognized that the plan would have to 
be modified from time to time to adjust it to conditions not foreseen 
when the plan was prepared, or to improve it as experience showed 
the necessity for such change. The principal amending laws have 
been those of 1913, 1918, ana 1920. The first two of these provided 
for simplifying the administration and correcting certain abuses; the 
1920 amending act increased the contributions and benefits and pro¬ 
vided for the eventual transfer of the sanatorium (tuberculosis) 
benefit to a new service in order to supply a more comprehensive 
course of treatment. Since the establishment of the system, two 
investigating committees have made exhaustive surveys of its work¬ 
ings. It is interesting to note that these committees, composed of 
members of different parties and representing different points of view, 
all seem to join in stating that the actual working of the plan was of 
distinct value to the persons insured. All of their recommendations 
were in the direction of extending and improving the system. The 
only change which has the appearance of lack of success in the system 
is the removal of the sanatorium benefit. The author of this change, 
the first minister of health, has stated that it was made for the pur¬ 
pose of introducing a nation-wide, intensive system of treatment 
which would be beyond the scope of a health insurance system. 


4 NATIONAL HEALTH INSURANCE itf GREAT BRITAIN. 

The history of health insurance in Great Britain is in some detail in 
the twenty-fourth annual report of the United States Commissioner of 
Labor, in which the latest information given is for the year 1909. 
It is now known that the British Government at that time had its 
experts at work preparing plans for the system here described, and 
the present report therefore may be said to take up the subject where 
the former study ceased. 

SUMMARY STATEMENT OF THE SYSTEM. 

By the act of December 16, 1911, which came into operation on 
July 15, 1912, a system of compulsory health and invalidity insurance 
was introduced into Great Britain. The following pages summarize 
the provisions of this act as amended by the legislation of 1913, 1918, 
1919, and 1920. 

INDUSTRIES AND OCCUPATIONS INCLUDED. 

The general rule is that the insurance includes all persons, men and 
women, 16 years of age or over, under any contract of service for 
which remuneration is paid. The most important limitation on this 
general rule relates to nonmanual employments. Persons employed 
at other than manual labor whose annual remuneration exceeds £250 
($1,217, par) are not included. Prior to July 1, 1919, this limitation 
was £160 ($779, par). 

The official Handbook of Approved Societies (1915) sums up the 
groups eligible for insurance as follows: 

1. Persons in employment by way of manual labor, regardless of earnings. 

2. Persons in any employment at a rate of remuneration not exceeding in value 
£160 [now £250], 

3. One who has been an insured person for two years or upward. 

4. One who has been an employed contributor and being of the age of 60 or upward, 
who shows to the satisfaction of the insurance commissioners [now the Ministry of 
Health] that he or she has ceased to be insurable as an employed contributor. 

It will be noted that there is now practically no age limit, though 
pecuniary benefits are not paid after the age of 70 is reached. The 
employments include agriculture, mining, industry, commerce, trans¬ 
portation, and public service. 

The persons exempt from the insurance are those who have rights 
to sickness and other benefits from certain specified sources, such as 
railway employees, school-teachers, etc., who are entitled to such 
benefits from existing funds. Casual employments are exempt unless 
the employment is in the regular line of the employer’s trade or busi¬ 
ness. 

If the person employed within the general terms of the law can 
prove that (1) he is in receipt of any pension or income of the annual 
value of £26 ($127, par) or more ana not dependent on his personal 
exertions, or (2) that he is ordinarily and mainly dependent on some 
other person for his livelihood, or (3) that he is dependent for his liveli¬ 
hood on earnings derived from an occupation which is not employ¬ 
ment as already defined, then he may be granted exemption by the 
authorities. 

Voluntary insurance is permissible only for persons who have been 
insured for two years or more. 


summary statement of the system. 


5 


DISABILITY PROVIDED FOR. 

The insurance is intended to provide for inability to work due to 
some specific disease or bodily or mental disablement. The pecuniary 
relief commences with the fourth day of such incapacity, while the 
medical relief is available from the beginning of sickness. There are 
two types of disability recognized by the law: First, that usually known 
as temporary disability; second, that usually termed invalidity. The 
first is expected to include cases lasting less than six months in a year, 
and the second, cases of longer duration or even permanent total dis- 
bility. The system is therefore a combined sickness and invalidity 
insurance system. The presence of the invalidity feature is respon¬ 
sible for the complicated financial arrangements of the system. 
Accidental injuries which receive benefits under the workmen’s com¬ 
pensation act are not usually included, but disability due to 
accidents not covered by the compensation act does entitle to bene¬ 
fits, unless by some legal process compensation or damages equal to 
or in excess of the regular benefits are secured. The carriers of the 
insurance may themselves take steps to secure such compensation 
or damage. Venereal diseases, even if due to misconduct, must re¬ 
ceive medical benefits and may receive pecuniary benefits. 

For the women included in the insurance, provision is made for 
inability to work on account of childbirth. The uninsured wife of 
an insured man also receives this benefit. 

THE BENEFITS. 

The benefits provided by the insurance are divided into two 

f roups—those administered by the insurance committees and those 
y the u approved societies.” 

The insurance committees have charge of (1) medical benefits, 
(2) sanatorium benefit (discontinued in 1921, except in Ireland), 
(3) sickness benefit, (4) disablement benefit, (5) maternity benefit, 
(6) additional benefits. It will be noted that there is no funeral 
benefit. 

Medical benefit .—This consists of such medical treatment as can 
consistently, with the best interests of the patient, be properly under¬ 
taken by a general practitioner of the usual professional skill. It also 
includes the provision of medicines and of such medical and surgical 
appliances as are approved by the regulations issued by the insurance 
authorities; that is, by the Ministry of Health or the Scottish Board 
of Health. As soon as a person is accepted as a member by an ap¬ 
proved society, this benefit becomes available without any waiting 
period. The benefit must be provided immediately on the beginning 
of the disability. 

Voluntary contributors are entitled to medical benefit in the same 
manner as the regular contributors, but if their annual income exceeds 
£250 ($1,217, par), no right to this benefit exists. Their dues, how¬ 
ever, are reduced 2 pence (4 cents, par) weekly. 

In the rare cases where the insurance authorities are satisfied that 
the insured persons in any area are not receiving adequate medical 
service, they may make special arrangements to provide such ser¬ 
vice, or they may allow the beneficiaries to provide themselves with 
service and pay them for the cost of it. 


6 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN". 


Sanatorium benefit. —Prior to 1921 this benefit consisted of treat¬ 
ment in a sanatorium or similar institution, or at home, provided for 
insured suffering from tuberculosis, or such other diseases as might 
be designated by the minister of health (formerly by the local 
government board). No diseases other than tuberculosis have ever 
received treatment under the law providing for this benefit, so that 
it has always been a tuberculosis benefit. Under the provisions of 
the public health (tuberculosis) act of 1921 (11 and 12 Geo.V, ch. 12) 
a general tuberculosis service for the entire population (insured and 
uninsured) was instituted; the insurance system acts as a cooperating 
service under the law and by complying with certain conditions has 
representation on the governing bodies which administer the new 
tuberculosis service. The new act does not apply to Ireland. 

Sickness benefit. —This consists of a periodical payment to insured 
persons rendered incapable of work by some specific disease or by 
bodily or mental disablement of which notice has been given, com¬ 
mencing on the fourth day of such incapacity and continuing for a 
period not exceeding 26 weeks. If the disability continues longer 
than 26 weeks, the disablement benefit (described below) begins. 
These two benefits cease when the age of 70 is reached, as the old-age 
pension begins at that age. Sickness benefit is not paid in maternity 
cases. As some supervision of the beneficiary is required, the sick¬ 
ness benefit is not paid while the patient resides outside of the United 
Kingdom. 

If this benefit is drawn for a period of 26 weeks, application for 
benefit for another case of sickness will be approved only when at 
least 12 months have elapsed from the date of last receipt of benefit. 

The societies are authorized to refuse or suspend the benefit if the 
sickness was caused by misconduct or if recovery is delayed by failure 
to observe the rules. 

The “ordinary” rate of sickness benefit is 15 shillings (S3.65, par) 
per week for men and 12 shillings ($2.92, par) per week for women. 

The sickness benefit is payable only after the contributor has been 
insured 26 weeks and has paid 26 contributions. If a person ceases 
to be insured and then later again becomes an employed contributor, 
a waiting period (or what may be termed a probationary period) is 
again required; as the law expresses it, “he shall be treated as if 
he had not previously been an insured person.” 

Disablement benefit. —This consists of a periodical payment in case 
of a disease or disablement which has exhausted the sickness benefit. 
The rate is 7 shillings 6 pence ($1.83, par) per week for men and women 
alike and continues for the duration of the disablement. A waiting 
period (or probationary period) of 104 weeks, for which a like number 
of contributions has been paid, is required. The benefit begins on 
the day after sickness benefit has been exhausted, but only after 
104 weeks of insurance. 

Maternity benefit. —This consists of a sum of money payable after 
contributors have been insured 42 weeks (formerly 26 weeks). An 
insured man is entitled, on the confinement of his wife, to receive 
from the society the sum of 40 shillings ($9.73, par), the benefit being 
the wife’s property. If the wife is also insured, she is entitled to 
receive from her society a further sum of 40 shillings, making in all 
80 shillings ($19.47, par). In order not to place in an unfavorable 
position the insured woman whose husband is not insured, the double 


stjmmahy statement oe the system. 


1 


benefit of 80 shillings is paid to her also, in this case the whole amount 
coming from her society. An unmarried woman is entitled, on con¬ 
finement, to a benefit of 40 shillings. 

The maternity benefit does not carry with it the right to any med¬ 
ical attendance or medicines, nor may the insured woman receive 
any sickness benefit for four weeks after the date of confinement, 
unless there is some disease or disablement not connected directly or 
indirectly with the confinement. However, the model rules issued 
by the commissioners state “ a woman in respect of whom this benefit 
is payable must be attended in her confinement by a duly qualified 
medical practitioner or by a midwife possessing the prescribed quali¬ 
fications. 

The 40 shillings benefit paid in respect of a wife’s insurance carries 
with it the obligation to abstain from remunerative employment for 
four weeks after the confinement. 

In order to make sure that the maternity benefit reaches the widest 
possible group of insured women, it is payable even though the woman 
has already exhausted her 26 weeks of sickness benefit or even if she 
has been suspended from sickness benefit on account of arrears. 
Similarly, when the husband is in arrears or is otherwise disqualified, 
the wife’s society must pay the 80 shillings benefit. 

An additional aid in maternity cases is provided by section 10 (4)b 
of the act of 1911, under which no regard is to be taken of arrears of 
contributions during the two weeks before and four weeks after con¬ 
finement in the case of an insured married woman. This is equivalent 
to exemption from contributions for these six weeks. 

Additional benefits .—Section 37 of the 1911 act provides that where 
the actuarial valuation of an approved society shows that there is a 
surplus over liabilities, the society may provide for its members and 
their dependents certain additional benefits. The fourth schedule 
appended to the 1911 act gives a list of the permissible extensions 
of benefits. These may be summed up as consisting of increases in 
the ordinary benefits, expecially in cases where a member has de¬ 
pendents, an addition to the old-age pension provided by the act of 
1908, grants to members in distress, etc., but such additional bene¬ 
fits may not include a funeral benefit. 

These additional benefits are to be paid when the periodical valua¬ 
tion of a society shows the presence of a surplus. Because of war 
conditions, it was not feasible to make such an actuarial valuation 
until the arrival of peace. 

SOURCES OF INCOME. 

The funds of the insurance system are derived from three sources: 
(1) The contributions of the insured person; (2) the contributions of 
the employer; (3) grants from the national treasury. 

Contributions .—The so-called “employed rate” is as follows: The 
contributions for men are 10 pence (20.3 cents, par) weekly; for 
women, 9 pence (18.3 cents, par) weekly. This is divided as follows: 
The man pays 5 pence (10.1 cents, par), the employer 5 pence; the 
woman pays 4 pence (8.1 cents, par), the employer 5 pence. These 
rates, it will be noted, are “flat” rates, being uniform for the whole 
class of “employed contributors.” 


8 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


“Employed contributors” form the great majority of the insured 
persons, but there are special groups of so-called “low-wage earners” 
for whom special provision is made. 

Arrears .—Arrears due to sickness or disablement and, in the case 
of woman members, due to maternity, are disregarded in making up 
the accounts. The general principle is that any loss which a society 
suffers by the nonpayment of a member’s dues in one year shall be 
made good to the society by the reduction of his benefits in the 
following year. The arrears of one year are canceled in the next 
year, even if no benefit is claimed, so that the member in arrears 
makes, as it were, a fresh start each year. 

FINANCIAL ADMINISTRATION. 

The finances of the system are based on a plan of level premiums; 
that is, the contributions are uniform for all ages regardless of the 
higher sickness and disablement rates in the older age groups. As 
this plan provides both sickness and validity insurance, the accu¬ 
mulation of a reserve is necessary. This combination makes the 
plan extremely involved. 

The weekly dues of 5 pence (10.1 cents, par) for men and 4 pence 
(8.1 cents, par) for women are paid by deductions from wages; the 
employer adds 5 pence to each of these amounts and affixes special 
stamps of the proper value to the card of the employee on the dates 
when wages are paid. The stamps are purchased from the post 
office, which deposits the receipts in the national health insurance 
fund. From this fund the money is drawn for the payment of 
benefits and for expenses of administration. 

The portion of the expense defrayed by the National Government 
was, at the start, two-ninths of the cost of benefits and of administra¬ 
tion for the men, and one-fourth of these expenditures for the women. 
At present it is two-ninths for men and women alike. 

The cost of administration in the societies may not exceed 41 pence 
(83.1 cents, par) per member annually. If there is a deficiency in 
the administration account, an assessment must be levied on the 
members. 

The rates of dues and the schedule of benefits of the system were 
computed on the basis of being self-sustaining for a person who 
entered the insurance at the age of 16; but for a person who entered 
at a later age the contributions were not considered to be sufficient 
to provide the benefits. The system thus began with a liability 
which was estimated as being £87,000,000 ($423,385,500, par). To 
cover this amount each person entering the insurance has credited 
to him a theoretical credit—called a “reserve value.” At the start 
this amount was to be made up by setting aside as a sinking fund a 
portion of the weekly dues of each contributor, as follows: For the 
men, If pence (2.4 cents, par); for the women, If pence (3 cents, par). 
By the act of 1918 the deduction in the case of women was made 
If pence (3.2 cents, par). It was originally estimated that these 
deductions would cancel the “reserve values” at the end of a period 
of about 18 years; it is now believed that this period will be somewhat 
longer than that. 

A special committee appointed in 1916 to make a study of the 
finances of the system repoTted that the funds available for women’s 


SUMMARY STATEMENT OF THE SYSTEM. 


9 


benefits were inadequate, and recommended that part of the deduc¬ 
tions just described should be devoted to current expenses. The 
1918 law provided (sec. 1) that part of the sums should be applied 
to the accumulation of two special funds—the central fund and the 
contingencies fund. The central fund is to receive one-eighth and 
the contingencies fund seven-eighths of a sum representing in the 
case of men two-thirds of a penny (1.4 cents, par) and in the case 
of women one-half of a penny (1 cent, par) for each weekly contribu¬ 
tion paid in respect of a member of a society. 

The central fund is intended to meet any deficit arising out of an 
abnormal rate of sickness. It receives in addition to the above- 
mentioned sum, and the interest which has accumulated on it, a 
sum of £150,000 ($729,975, par) annually from Parliament. 

In general it may be said that the purpose of the contingencies fund 
is to meet any deficit which appears when an actuarial valuation is 
made; however, the amounts apportioned to any one society belong 
to the credit of that society only and may not be used to meet a 
deficit in any other society. 

Besides these two funds, the 1918 act also creates a women’s 
equalization fund, to be used in assisting societies in meeting their 
liabilities arising out of the sickness claims of women. It is distrib¬ 
uted to the societies pro rata on the basis of the number of married 
woman members. In general it may be said that this fund is to 
meet the disabilities due to childbearing. 

GENERAL ADMINISTRATION. 

Ministry of Health .—The Ministry of Health act of June 3, 1919, 
made a number of important changes in the administration of the 
insurance system. This act, as far as it applies to health insurance, 
came into force July 1, 1919, and other powers are being added to 
it from time to time. The powers and duties of the new ministry 
include the supervision and administration of the entire insurance 
system. 

National Health Insurance Joint Committee .—Prior to June, 1919, 
the system was in charge of four bodies known as insurance com¬ 
missioners, there being one each for England, Scotland, Wales, and 
Ireland. Over these four boards was an organization composed of 
representatives of each, called the National Health Insurance Joint 
Committee, a federated body whose principal function was to take 
charge of all matters common to the four boards, especially the 
actuarial problems. 

By the terms of the Ministry of Health act, the joint committee 
is composed of the Minister of Health as chairman, the secretary for 
Scotland, the chief secretary for Ireland, and one other person ap¬ 
pointed by the minister to represent the Welsh insurance system. 
Except for this change of personnel, the previous constitution of the 
joint committee and its rights and duties are unchanged. All of 
the powers and duties formerly belonging to two of these bodies, the 
insurance commissioners for England and the insurance commis¬ 
sioners for Wales, are henceforth to be exercised by the Ministry 
of Health, and all their employees are transferred to the new min¬ 
istry. 


10 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


The most important work carried on by the joint committee is 
that relating to the actuarial features of the insurance; this includes, 
for instance, the calculation of the rates of contributions, reserve 
values, etc. An actuarial advisory committee has aided the joint 
committee since the commencement of the act. 

Until the passage of the Ministry of Health act, there was attached 
to the joint committee a special committee on medical research, to 
make special investigations on matters relating to any disease to 
which the insured persons are subject. The expense of these inves¬ 
tigations is provided for by special appropriations by Parliament, 
the amount of 1 penny (2 cents, par) per insured person being granted. 
In the future this research committee is to be entirely independent 
of the insurance system. 

Insurance commissioners .—In the future, the administration will be 
divided into three parts, one for England and Wales and one each 
for Scotland and Ireland. 

The former insurance commissioners are now the insurance de¬ 
partment of the Ministry of Health, and may be used as typical in 
describing the scope and organization of these bodies. The ministry 
may appoint such officers, inspectors, and other employees as they 
see fit, subject to certain supervision of the treasury authorities; they 
may sue and be sued and hold property. They have authority to 
issue regulations authorized by the insurance laws; they approve 
the statutes and supervise tne administration of the approved 
societies. 

The ministry have an advisory committee to give advice and 
assistance in making regulations for the administration of the laws; 
this committee consists of representatives of the employers, of the 
approved societies, and of the medical profession, and of such other 
persons as the ministry may appoint, of whom at least two must be 
women. 

Approved societies .—When the plans for the health insurance 
system were formulated, the United Kingdom was covered by a 
network of friendly societies, trade-unions, commercial insurance 
companies, sick clubs, establishment funds, and similar voluntary 
organizations which provided a variety of benefits for sickness, 
accidental injury, superannuation, etc. Many of these organizations 
had a long history of usefulness in providing relief for distress from 
these causes, and it was decided to use the societies as the carriers 
of the pecuniary benefits. The insurance laws therefore provide 
that the insured persons shall group themselves into self-governing 
bodies—the organizations just named—which shall be responsible 
for the administration to their members of the pecuniary nenefits 
provided by the system. These societies, if they meet the require¬ 
ments of the law, are recognized by the insurance commissioners as 
“ approved societies.” The general requirements are that the 
society shall be self-governing, not conducted for profit, and generally 
be in a position to carry out the provisions of the law. In order to 
permit any organization to continue such activities as are not cov¬ 
ered by the law, the societies may have a special section for admin¬ 
istering the provisions of the insurance acts, whose accounts must be 
kept separate from other activities. Special arrangements are made 
for federating societies whose membership is not large enough to 
provide an adequate basis to carry the risks of an influenza epidemic 


SUMMARY STATEMENT OF THE SYSTEM. 


11 


or similar tax on their resources. These societies were required to 
enact by-laws which were submitted to the commissioners for ap¬ 
proval and which complied with the general scheme of administra¬ 
tion. They could accept such members as they saw fit, except that 
they could not reject an applicant solely on account of age. 

A person may not be a member of more than one society for the 
purpose of State insurance. 

Tne principal functions of the approved societies are the payment 
of cash benefits, the keeping of records of the members, and the 
supervision of beneficiaries. 

Insurance committees .—For each county and county borough of ' 
the United Kingdom there is a body called an insurance committee, 
which has charge of the medical and (formerly) sanatorium bene¬ 
fits. The members of these committees in England and Wales are 
appointed by the Ministry of Health. The committees must be 
composed of not less than 40 nor more than 80 members, consisting 
of representatives of the insured persons, of the county govern¬ 
ment, and of the medical profession, and other persons appointed by 
the Ministry of Health. 

Each committee must make such arrangements with duly quali¬ 
fied medical practitioners in the county as will assure to the in¬ 
sured persons adequate medical attendance and treatment. The 
committee prepares a list of doctors who are willing to attend in¬ 
sured persons, and this list, called the “panel,” must be duly pub¬ 
lished. Usually it is displayed in each post office as well as dis¬ 
tributed among the insured persons. Each of the latter may select 
from the panel the doctor whom he desires for his physician. 

The committee must also prepare and publish lists of persons or 
firms who are willing to supply drugs, medicines, and appliances to 
insured persons in accordance with regulations made by the authori¬ 
ties. The committee must make in advance an agreement with 
the druggists (“chemists”) as to the schedule of prices for drugs, 
etc., subject to the approval of the authorities. 

The administration of the sanatorium benefit was originally in 
the hands of the committees entirely; later, special grants were 
made by Parliament to various local organizations engaged in com¬ 
bating tuberculosis; but since the enactment of the Ministry of 
Health law, all this work has been placed in charge of the ministry, 
and under the act of 1920 was removed from the insurance system 
and placed under a special health-service system of the Ministry of 
Health. 

DEPOSIT CONTRIBUTORS* FUND. 

As the societies could reject an applicant for any reason except 
age, it was expected that there would be a number of persons who, 
on account of ill health or other reason, could not obtain member¬ 
ship. For this group a special organization, “the deposit con¬ 
tributors’ fund” (originally called the post-office fund), was created. 

It was expected that this fund would have close to a million mem¬ 
bers, but at the close of the year 1919 the number was estimated to 
be 450,000. 

The deposit contributors are entitled to such benefits as the sum 
to their credit will provide. They may, for instance, draw sickness 


12 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


benefit only until they have exhausted the amount standing to their 
credit. Such contributors are in a distinctly less favorable position 
than the regular contributors. 

PERSONS INCLUDED. 

COMPULSORY INSURANCE. 

The fundamental rule is that every person, man or woman, who 
is engaged in manual employment m the United Kingdom under 
any contract of service or apprenticeship, or in nonmanual employ¬ 
ment and earning less than £250 ($1,217, par) annually, is included 
within the terms of the insurance as a compulsory member—usu¬ 
ally referred to as an “employed contributor.” 

Under the act of 1911 the limit of remuneration was £160 ($779, 
par); because of the increase of wages during and following the war 
the act of 1919 raised the exemption limit in order to prevent the 
loss of the insurance rights of persons who desired to continue their 
insurance. 

By far the greatest number of persons included in the insurance 
have become members of one of the “approved societies” which 
administer the pecuniary benefits. The official Handbook of Ap¬ 
proved Societies (August, 1915, and Supplement, 1918) thus describes 
the groups of persons eligible for membership in these societies: 

1. Persons in employment by way of manual labor. 

2. Persons in any employment at a rate of remuneration not exceeding in value 
£250 [$1,217, par] a year. 

3. Persons engaged in some regular occupation and wholly or mainly dependent 
for their livelihood on the earnings derived from that occupation, and who have a 
total income, including earnings, of not exceeding £250 a year. [The act of 1918 
provided that no new admissions to this group should be made after July 1, 1918.] 

4. One who has been an insured person for two years or more. 

5. One who has been an employed contributor and, being of the age of 60 or up¬ 
ward, who shows to the satisfaction of the insurance commissioners that he or she 
has ceased to be insurable as an employed contributor. 

One of the difficulties experienced in the administration of the 
original act arose from the large number of classes of membership 
provided for; under the 1911 act there were 23 classes. This was 
reduced somewhat by the 1913 act and finally the 1918 act brought 
the number down to 8. As there are also two classes of deposit 
contributors, the total number of membership classes is now 10. 
The names and symbols used in designating the 8 classes are as 
follows: 

Classes of Members, 1918. 

A. —Men employed contributors. 

A (M).—Men employed on foreign trade ships. 

B. —Men in Navy, Army, or air forces. 

C. —Men voluntary contributors. 

E. —Women employed contributors. 

E (M).—Women employed on foreign trade ships. 

F. —Women voluntary contributors. 

K.—Women entitled to special benefits on or after marriage. 

To this schedule should be added those persons, men and women, 
who do not become members of approved societies and who join the 
so-called deposit contributors’ fund. 


PERSONS INCLUDED. 


13 


If a question arises as to whether an employment or a person is 
included within the insurance, the matter is to be decided by the 
minister, with the right of appeal to a judge of the high court selected 
to hear such cases, whose decision is final. As such a hearing in¬ 
volves an elaborate procedure, efforts are usually made to decide 
the matter without recourse to the courts. That these efforts have 
met with considerable success is shown by the fact that in the years 
1917 to 1919, inclusive, only two cases were appealed to the courts. 

VOLUNTARY INSURANCE. 

When the plan of the British system was prepared, it was considered 
necessary to justify the State contribution to those who were com¬ 
pulsorily insured, by offering an equal grant to the same economic 
group of the population to whom the compulsory feature did not 
apply because it chanced that they were working on their own ac¬ 
count instead of being in the service of some employer. Accordingly 
a plan of voluntary insurance was prepared for the benefit of per¬ 
sons who were engaged in some regular occupation on which they 
were wholly or mainly dependent and from which they derived an 
income not greater than that of the persons required to insure. 
The plan devised and adopted in the act of 1911 was rather compli¬ 
cated and demanded a large amount of administrative labor to carry it 
out. The number of persons who took advantage of this opportunity 
proved to be much smaller than had been expected. The depart¬ 
mental committee which reported in 1916 found that there were only 
28,000 persons at that time who had taken advantage of the oppor¬ 
tunity in the four years that it had been open. After considering 
the various aspects of the problem, the committee recommended that 
the class of voluntary contributors be discontinued, mainly on ac¬ 
count of the high cost of administration, but partly because of the 
small numbers who had accepted the offer. The act of 1918 adopted 
the recommendations of the committee by abolishing voluntary in¬ 
surance, but leaving it open to those who had been insured as volun¬ 
tary contributors at the time and to those described in the next 
paragraph. 

At the present time the right to voluntary insurance is restricted 
to persons who have been compulsory members in full standing, but 
who have ceased to be included within the groups covered by the com¬ 
pulsory provisions, but not including married women, for the reason 
stated below. Section 7 of the act of 1918 provides that those per¬ 
sons who had been employed contributors for 104 weeks, that is, 
who had reached the status of full benefits, should thereafter have 
the right to voluntary insurance. Voluntary insurance at the present 
time is intended merely to protect the interests of persons who have 
been employed contributors and who pass to a noninsurable status. 
It was pointed out that poor health was very frequently the reason for 
a person leaving employment and setting up in business in a small way 
for himself; it wouldtherefore be an injustice to suchpersons to abolish 
voluntary insurance altogether, as many society officials had urged. 

Women employed contributors who give up employment on mar¬ 
riage may not continue as voluntary contributors. This exclusion 
was adopted on the advice of the friendly societies, who pointed out 
that supervision in such cases was practically impossible, that the 

104936°—23—Bull. 312-2 


14 NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 

test of ability to work could hardly be applied and that the sickness 
rate of married women was known to be high. A married woman in 
employment is, of course, not affected by this ruling* 

DEPOSIT CONTRIBUTORS. 

Persons who are in poor health and clearly substandard risks for 
any insurance system were provided for by organizing the deposit 
contributors’ fund, into which they are admitted on application. 
The societies which act as carriers of the insurance have aided mate¬ 
rially in settling this question by waiving any right to medical ex¬ 
amination, so that the person in poor health has had practically no 
difficulty in securing admission to a society. 

In the future new entrants will, as a rule, come into insurance at 
the age of 16, when poor health or serious disease is least frequent, 
and the problem will be one of diminishing importance. 

DEPENDENTS OF INSURED PERSONS. 

The only member (not insured) of the family of an insured man 
who is entitled to benefit at present is the wife of an employed con¬ 
tributor, who receives maternity benefit. If after a valuation a 
society is shown to have a surplus over the capital sum necessary to 

E rovide the statutory (or minimum) benefits, then certain specified 
enefits may be provided for the dependents of an insured person. 

PERSONS GRANTED EXEMPTION FROM COMPULSORY INSURANCE. 

Ordinarily a person subject to the compulsory provisions of the 
law must become a member either of an approved society or of the 
deposit contributors’ fund. On application, however, a person may 
be granted a certificate of exemption from insurance. At present 
this certificate may be issued on any one of four grounds: 

1. That the applicant is in receipt of income or pension of the an¬ 
nual value of £26 ($126.53 par) or upward, not dependent upon his 
personal exertions. 

2. That he is ordinarily and mainly dependent for his livelihood 
upon some other person. 

3. That he is ordinarily and mainly dependent for his livelihood 
on the earnings derived by him from an occupation which is not em¬ 
ployment within the meaning of the insurance acts. 

4. That he is intermittently employed. 

The first three of the foregoing grounds for exemption can be de¬ 
termined from the personal history of the applicant. The question 
of intermittent employment is now defined by regulations issued 
under authority of section 8 of the 1918 act; the applicant must now 
prove that he has been employed less than 13 weeks in each of two 
successive contribution years. 

INDUSTRIES AND EMPLOYMENTS INCLUDED. 

The industries and occupations subject to compulsory insurance 
can be stated in brief form. The general rule is that the law covers 
all those occupations where there is a contract of service, first, if 
the occupation is manual, regardless of the amount of remuneration, 
and, second, if the occupation is nonmanual, if the remuneration is 
less than £250 ($1,217, par) annually. This includes agriculture, 


DISABILITY PROVIDED FOR. 


15 


forestry, quarrying, mining, manufacturing, commerce, transporta¬ 
tion by land and water, banking, insurance, building trades, “out¬ 
workers/’ domestic service, etc. Persons employed in the navy, 
army, and air forces are also included, as are the civil employees 
of the various Government offices (if they are not otherwise insured). 

There is a long list of exceptions to this general statement of the 
occupations covered; most of these exceptions relate to employments 
in which equivalent benefits are provided under some other arrange¬ 
ment. Thus employment by the Crown, by a local authority, by a 
railway company where equal provision in case of sickness or dis¬ 
ablement is made, are exempt employments. Similarly, casual 
employment otherwise than for the purposes of the employer’s 
trade or business and subsidiary employment which is not the prin¬ 
cipal means of livelihood are exempt. This brief summary is not 
complete, but it serves to show the basis on which employments are 
excluded from the insurance. 

DISABILITY PROVIDED FOR. 

The purpose of the insurance is, first, to restore the insured person 
to health it possible, and, second, to afford some measure of pecuniary 
relief for the loss of wages. According to the phraseology of the law, 
its benefits are to be provided for inability to work, due to some 
specific disease or bodily or mental disablement. The law recognizes 
two types of disability: First, temporary disability lasting not more 
than 26 weeks, and, second, prolonged disability, or invalidity, con¬ 
tinuing after the 26 weeks’ period just referred to and covering a life¬ 
time if necessary. The system is therefore a combined sickness and 
invalidity insurance organization. 

For the women included among the insured persons, pecuniary 
benefit is paid for inability to work on account of childbearing; this 
includes benefit during both pregnancy and confinement. This 
benefit is also provided for the uninsured wife of an insured man. 

As sickness and disablement benefits are paid for inability to work, 
they must be paid for accident cases as well as illness. When the 
injured person has a claim for compensation or for damages the 
society has the right to recover the amounts it advances from the 
person liable for compensation or damages. The laws carefully 
prescribe the procedure to be followed in such cases. It will be 
recalled that tne British workmen’s compensation act also includes 
certain occupational diseases, thus relieving the health insurance 
system of this burden. Judicial decisions have established the right 
of the approved society to bring action, in the name of the injured 
person, to recover compensation or damages. 

The disability due to sickness caused by misconduct, especially 
disobedience of rules, is not ground for receiving any pecuniary 
benefit, though medical and sanatorium benefit must be provided. 
Prior to the enactment of the act of 1918, the societies could exclude 
persons from pecuniary benefit in the case of venereal disease, on 
the ground of misconduct. Under section 46 of the 1918 act, the 
executive body of a society was authorized to make amendments 
to the society’s rules, specifically providing for such payment pending 
its adoption by the society. The first report of the Ministry of Health 
states that such action was generally taken by the societies, 


16 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


An unmarried woman may not be refused sickness or disablement 
benefit on the ground that disability due to pregnancy was caused by 
misconduct (act of 1918, section 12-3). The welfare of the child is 
of course the reason for this provision. 

BENEFITS. 

The benefits provided by the system are the following: 

1. Medical benefit. 

2. Sanatorium benefit (transferred to other authorities during 
1921). 

3. Sickness benefit. 

4. Disablement benefit. 

5. Maternity benefit. 

6. Additional benefits. 

These benefits are listed in the order in which they appear in the 
law. They provide first for medical aid for the return to health of 
the insured person if possible, a pecuniary benefit to replace in a 
measure the wage loss, the grant of a sum of money on the occasion 
of childbirth and, if the financial status of the carrier will permit, an 
extension of these benefits. There is no funeral benefit, such as 
most compulsory systems of health insurance provide. 

The benefits are described in the order here given. 

MEDICAL BENEFIT. 

The medical benefit, in brief, consists of the provision of doctor’s 
services and of medicines, appliances, etc. As in any given area 
there would probably be a large number of approved societies 
administering the pecuniary benefits, it was necessary to create a 
special body to provide and supervise the medical benefit. This 
organization is called the “insurance committee,” and all features 
of this benefit, including such as may be provided under “ additional” 
benefits, must be administered by and through this committee. 
As a rule a committee is appointed for each county and county 
borough; if the Ministry of Health so orders, certain committees 
may be combined. 

Qualifications.—A person is qualified for medical benefit as soon 
as he becomes a member; there is no waiting period and the law 
makes no mention of any specific number of contributions to be paid, 
though a person of 65 or over on entering must have 26 contributions 
to his credit before he is entitled to this benefit. Under the 1920 
act, the minister is authorized to make regulations under which the 
funds of approved societies will be debited with such a sum as 
represents the estimated cost of medical benefit in respect of each 
member who attains the age of 70. The fact that a member’s 
contributions are in arrears does not affect his right to medical 
benefit; as long as he remains in insurance, the benefit must be 
provided. 

General arrangements for medical service .—The insurance com¬ 
mittee, after consultation with the local medical committee and the 
panel committee, must prepare and publish a statement of the 
terms upon which doctors are to furnish medical service; all such 
statements must have the approval of the minister and must con¬ 
form to the general regulations issued by him. The insurance com¬ 
mittee must likewise publish a “medical list” (i. e. ; the “panel”) 


BENEFITS. 


17 


containing the names of the physicians who have accepted service, 
as well as their residence and office addresses, office hours, etc. This 
list must be made available for insured persons in a convenient 
manner, and copies must be furnished to the panel and to the 
pharmaceutical committees, as well as to the parties furnishing 
drugs, medicines, etc. 

If the minister is satisfied that the insured persons in any area 
are not receiving satisfactory medical treatment under the panel 
system, he may authorize the insurance committee to make such 
other arrangements as will secure better service, with due regard 
to the funds available. He may also allow the insured persons in 
such cases to make their own arrangements. 

Rather elaborate arrangements are provided under the medical 
benefit regulations to permit certain insured persons to provide 
their own medical service, and a slight reduction in the contribution 
is allowed in such cases. As these cases are exceptional, it is only 
necessary to state that an account of the arrangements will be 
found in the fourth schedule of the Medical Benefit Regulations of 
1920. The act of 1920 provides that no voluntary contributor 
whose income exceeds £250 ($1,217, par) may have medical benefit; 
in addition, the insurance committee may exclude those insured 
persons whose income exceeds a specified limit. 

Allocation .—Each insured person is supplied with a “ medical 
card,” which must be used for purposes of identification whenever 
he applies for treatment. From the “medical list” he selects the 
physician by whom he wishes to be treated and either brings or 
sends the card to the doctor’s office for acceptance; the latter of 
course may decline to accept the applicant, in which case he either 
selects another doctor or, if he fails to do this, is assigned to another. 

The insurance committee and the panel committee must jointly 
draw up a plan for the allocation of insured persons among the 
doctors on the panel. It has been found that a large number of 
insured persons have no special preference for a particular doctor 
and are entirely willing to have their medical adviser assigned. The 
plan just referred to must also provide for other details of medical 
service, the feature most often referred to being the limitation of 
the number of insured persons on the list of one physician. The 
1920 regulations restrict the number of names on the list of a doctor 
who practices without an assistant or partner to 3,000, though it 
frequently occurs that many more than this number of persons 
apply to one doctor for acceptance. The plan must make provisions 
for distributing the excess, either by removing names or by securing 
an assistant or partner for the practitioner. 

The insurance committee and the panel committee are required to 
agree to a limit for each area, subject to this maximum of 3,000, and 
in one-third of the areas the maximum is fixed at 2,500; in some 
areas it is 2,000. These large lists, however, are not at all general, 
as may be seen from the fact that on January 1, 1921, about 34 per 
cent of the doctors had less than 600 persons on their lists; another 
30 per cent had between 600 and 1,200; about 22 per cent had between 
1,200 and 2,000; and only 14 per cent had above 2,000. The num¬ 
ber of practitioners with 3,000 names or more on their lists was less 
than 300. 1 The number of names on a list, of course, should be care- 

1 Second annual report of the Ministry of Health, 1920-21. Cmd. 1446. P. 43. 



18 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


fully distinguished from the number of patients given treatment. It 
is estimated that about 60 per cent of the insured persons apply for 
treatment each year. 

If an insured person so desires, he may change his doctor on the 
last day of June or of December in any year by giving notice in writing 
to the insurance committee; the change may also be made by mutual 
agreement between the insured person and the doctor who has been 
treating him, in which case the change must be reported to the insur¬ 
ance committee by the new doctor within seven days. As there is 
a large amount of clerical work involved in the listing of these 
changes, the aim of the insurance committee is to discourage them 
as much as possible. 

Drugs and appliances .—The insurance committee proceeds in a 
similar manner in regard to the supply of drugs, medicines, appli¬ 
ances, etc. After consulting with the local pharmaceutical commit¬ 
tee, the insurance committee prepares and publishes a list of persons 
or firms, also with the approval of, and under the regulations pre¬ 
scribed by, the minister. This list must be made available to the 
various committees affected, to the panel doctors, and to the insured 
persons. Arrangements must be made to have one or more places 
of supply open at all reasonable times, and where such a place is not 
reasonably accessible, arrangements must be made to have a panel 
doctor furnish medicines, etc. 

The minister is required to prepare a list of drugs, etc., called the 
“drug tariff,” which gives the prices at which artides are ordinarily 
to be supplied by the pharmacists. The prices must be varied from time 
to time to meet changes that may occur. The drug tariff includes 
the medicines, etc., usually called for by the doctors and specifies the 
method by which the prices of unusual drugs are to be ascertained. 

Besides the drug tariff, the minister specifies the appliances which 
must be supplied. As given in the second schedule of the 1920 
Medical Benefit Regulations, the “list of appliances” is as follows: 


List of Appliances. 


Adhesive plaster. 


Gauzes—Concluded. 
Sublimate. 
Unmedicated. 


Bandages, rolled: 
Calico. 

Crepe. 

Domette. 

Elastic-web. 

Flannel. 

India-rubber. 

Muslin. 

Open-wove. 


Gauze and cotton wool tissue. 


Lints: 

Boric. 

Sal-alembroth. 

Unmedicated. 


Ice bags: 

Check sheeting. 
India-rubber. 


laster of Paris. 


Catheters: 

Gum-elastic. 
Soft rubber. 


Protectives: 

Gutta-percha tissue. 
Jaconet. 

Oiled cambric. 

Oiled er. 

Oiled 


Cotton wools, absorbent: 
Boric. 

Sal-alembroth. 

Unmedicated. 


Splints. 



Gauzes: 

Boric. 

Carbolic. 

Double cyanide. 
Iodoform. 

Picric. 

Sal-alembroth. 


Wood wool. 


Tows: 

Carbolized. 
Unmedicated. 


Suspensory bandages: 
Cotton. 


BENEFITS. id 

The 1920-21 report of the Ministry of Health refers (p. 41) to the 
criticism sometimes made, that the insured persons do not get the 
11 proper and sufficient medicines” to which they are entitled because 
the doctors, it is said, hesitate to prescribe expensive medicines which 
they think necessary, since the regulations penalize doctors for exces¬ 
sive prescribing. The answer made to this criticism is that no doctor 
can be penalized in any way for prescribing particular drugs or appli¬ 
ances unless it be found after an investigation u that by reason of the 
character or quantity of the drugs or appliances so ordered or sup¬ 
plied, the cost is in excess of what may reasonably be necessary for 
the adequate treatment” of the insured person. This provision is 
necessary as otherwise doctors could prescribe medicines at public 
cost without any restriction whatever. The body to which is in¬ 
trusted the duty of investigating these questions of prescription is 
the panel committee of the area, consisting entirely of medical practi¬ 
tioners; it is intrusted with the duty not only of investigating the 
facts, but also of recommending the amount, if any, to be assessed 
against the doctor, in any case brought before the committee. This 
method was adopted at the request of the doctors themselves, who 
have undertaken that the work shall be fairly performed. 

Kind of treatment provided .—The treatment which a practitioner is 
required to give to his patients comprises such treatment as is of a 
kind which can, consistently with the best interests of the patient, 
be properly undertaken by a general practitioner of ordinary pro¬ 
fessional competence and skill. When necessary he shall indicate 
to the patient how special or unusual service may be secured. The 
practitioner must have proper and sufficient surgery and waiting 
room accommodation for his patients, and must have regular days 
and hours of consultation. He is required to visit and treat a 
patient whose condition so requires, at any place where the patient 
may be, if it is within the district previously agreed upon with the 
insurance committee. The practitioner must fill out such prescrip¬ 
tions as are necessary, on the forms provided for the purpose, though 
under certain circumstances he must provide drugs or appliances 
himself, especially in emergency cases. He must also fill out the 
medical certificates for his patients, and must keep such records of 
the diseases of his patients and of the treatment prescribed as the 
Ministry of Health may require. A practitioner may not demand 
from an insured person on his list any fee for the service or for any 
drug he is expected to provide. 

The law specifically excludes the provision of medical benefit in 
respect of a confinement. 

Certification .—The insured person who is incapable of work by 
reason of some specific disease or bodily or mental disablement must 
be given a certificate to that effect by the panel doctor. These cer¬ 
tificates are made out on blank forms supplied by the insurance 
committee for this purpose and no other kind of certificate is per¬ 
mitted. They are of three kinds: The first certificate, given when 
the incapacity is first determined; the second or intermediate certi¬ 
ficate, given after eight days of incapacity have passed, with renewals 
week by week during incapacity; and the final certificate, given 
when the patient is able to resume work. The certificate must be 
dated, must state the cause of the incapacity, and must be signed 
by the doctor personally. These certificates must be presented by 


20 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


the insured person to liis society when he submits a claim for the 
pecuniary benefits. 

In addition to the certificates above mentioned, several special 
forms are used, but in the main these three are all that are used in the 
great majority of cases. As this feature is of considerable impor¬ 
tance, the forms used are given below, being reproduced from Statutory 
Rules and Orders, 1921, No. 1780, dated November 22, 1921. 


Forms op Certificate. 

FIRST CERTIFICATE OF INCAPACITY FOR WORK. 

To. 

I hereby certify that I have examined you on the undermentioned date, and that 
in my opinion you were at the time of examination incapable of work by reason 
of*. 


fYou should come to see me again on.day next. 

Doctor’s signature . 

XDate of examination . 

%Date of signing . 

Any other remarks by doctor . 


INTERMEDIATE CERTIFICATE. 

To. 

I hereby certify that I have examined you on the undermentioned date, and that in 
my opinion you have remained incapable of work up to and including that date by 
reason of *.-.- 


fYou should come to see me again on.day next. 

Doctor’s signature . 

XDate of examination . 

%Date of signing . 

Any other remarks by doctor . 


FINAL CERTIFICATE. 

To.. 

I hereby certify that I have this day examined you, and that in my opinion you 
have remained incapable of work up to and including to-day by reason of *. 


and are fit to resume work after to-day. 

Doctor’s signature . 

Date of signing . 

Any other remarks by doctor . 


SANATORIUM BENEFIT. 

Prior to 1921 .—The benefit before 1921 was administered by the 
insurance committees, who were required to make arrangements to 
provide insured persons suffering from tuberculosis or 4 ‘any other 
such disease” with treatment in a sanatorium or a similar institution. 
These arrangements could be made with any persons or with any 
local authorities (except poor-law authorities) having the manage- 

* Here insert the name of the specific disease or bodily or mental disablement which renders the insured 
person incapable of work. 

f To be filled up at doctor’s discretion, where not obligatory under rules. 

% These dates should ordinarily coincide, and both lines may in that case be bracketed together and the 
one date inserted. 



























BENEFITS. 


21 


ment of such institutions, which must have received the approval of 
the Ministry of Health. Authority was expressly conferred on local 
authorities to make such contracts with insurance committees. 
As a matter of fact, the benefit has been restricted to cases of tuber¬ 
culosis. 

To secure this benefit, a member had to be recommended for treat¬ 
ment by the insurance committee. The number of beds available 
in sanatoriums has always been insufficient and the purpose of 
requiring the assent of the committee was to use the facilities first for 
cases where there was prospect of recovery and then for other cases. 

A member became qualified for benefit just as soon as he was 
insured (without any waiting period) and the right to benefit did not 
cease at the age of 70. 

After 1921 .—Under the provisions of the act of 1920, the sana¬ 
torium benefit is removed from the insurance system, though 
domiciliary treatment for tuberculosis is continued. According 
to the law approved May 12, 1921, entitled “ Public health (tuber¬ 
culosis) act, 1921” (11 and 12, Geo. V, ch. 12), this feature is to be a 
cooperative service jointly with the local authorities. The subtitle 
of the measure reads “ An act to make further provision with respect 
to arrangements by local authorities for the treatment of tubercu¬ 
losis.” Under the terms of the act, where the council of any county 
or of any county borough has made arrangements for the treatment 
of persons suffering from tuberculosis, including persons insured 
under the insurance acts, these arrangements are to be considered 
adequate and are to continue to receive the parliamentary grant in 
aid for that purpose. But where any such council fails to make 
adequate arrangements for the treatment of tuberculosis at or in 
dispensaries, sanatoriums, or other institutions approved by the 
Minister of Health, then the minister may make such arrangements 
as he may consider necessary for this purpose, though the council 
must first have an opportunity to be heard. In instituting such 
arrangements any expense incurred by the minister may be paid 
in the first instance out of moneys appropriated by Parliament; 
on demand the council shall later repay these expenditures, which 
are specifically stated to be recoverable as a debt due the Crown. 

The act also definitely authorizes the local authorities to include 
“aftercare” in the arrangements for the treatment of tuberculosis 
cases. 

The powers of the local councils may be exercised by a committee 
of its members, and this committee or subcommittee may include 
persons, such as members of insurance committees, who are quali¬ 
fied by training and experience in matters relating to the treatment 
of tuberculosis. At least two-thirds of such a committee or sub¬ 
committee must be members of the council. 

The expenses of the county councils incurred under the act are to 
be treated as expenses for general county purposes. Several county 
councils may form joint committees under the supervision of the 
Minister of Health in order to cooperate in this field. 

The change in the administration of this benefit occurred on 
May 1, 1921. As stated above, a part of the tuberculosis treatment 
still remains under the insurance authorities; if the insured person 
can be given treatment in his home (domiciliary treatment), it is 
provided by the insurance practitioner under agreements made 


22 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


between the latter and the particular insurance committee, because 
section 4(3) of the act of 1920 specifically includes in the medical 
benefit such attendance and treatment for tuberculosis. The cost 
of the service is defrayed by allotting an amount equal to that 
portion of the sanatorium benefit fund which was previously devoted 
to the remuneration of those practitioners for the domiciliary treat¬ 
ment of tuberculosis. The essential change is in regard to the 
provision of institutional treatment. Under the revised scheme of 
contributions instituted by the act of 1920, insured persons and their 
employers no longer contribute toward the cost of this treatment, 
and the insurance committees no longer have the duty of making 
arrangements for the institutional treatment of insured persons 
suffering from tuberculosis. The county and county borough 
councils will provide institutional treatment for insured persons 
direct, as well as for noninsured persons. Special measures have 
been taken to provide for close cooperation between the insurance 

E ractitioners and the tuberculosis officers of the councils; provision 
as also been made to enable the councils to supply extra nourish¬ 
ment to tuberculous persons (insured and noninsured) in their 
homes, in continuation of the service previously provided by the 
insurance committees. 

In Wales, the provision for tuberculosis treatment is to be con¬ 
tinued in cooperation with institutions conducted by the King 
Edward VII Welsh National Memorial Association. The act does 
not apply to Scotland or Ireland. In Ireland the sanatorium 
benefit is to be continued. In Scotland the Scottish Board of Health, 
by Statutory Rules and Orders, 1920, No. 2181-S.108, terminated 
the sanatorium benefit on January 1, 1921, and transferred the 
care of tuberculosis patients in institutions to the local authorities, 
together with such surplus funds, records, etc., as belonged to this 
work. 

The reasons for the removal of the sanatorium benefit from the 
insurance system were set forth by the Minister of Health at the time 
of the discussion of the act of 1920. According to the minister, 
there has not been a failure to secure results under the insurance 
benefit, but in order to secure effective result^ for the whole popu¬ 
lation there is needed a more comprehensive plan of attack than is 
possible under an insurance system. In the House of Commons 
Debates for May, 1920, page 221, occurs the following discussion, led 
by Doctor Addison, the Minister of Health: 

Doctor Addison. The purpose of taking sanatorium treatment out of the bill is 
because we contemplate a health service which will make use of all the general 
health services which are assisting in the treatment of tuberculosis in one form or 
another, including a considerable amount of work done in respect of tuberculosis 
in, say, poor-law infirmaries. Any improved health system must be sufficiently 
comprehensive; and as experience nas gone on we see more and more that you have 
to have a considerable organization and set up a service beyond the sanatorium 
and before it. There is, for example, the tuberculosis dispensary which is pro¬ 
vided and maintained by the various local authorities. Then sanatoriums have, 
with few exceptions, been provided by the great local authorities—the county 
councils, etc.—and these, with few exceptions, have made arrangements for the 
reception of their cases into the institutions. 

We have found more and more as the result of the war that a great deal of the expendi¬ 
ture incurred in sending people to sanatoriums was wasted. A large percentage went 
back to their trades, which perhaps imposed heavy burdens beyond their powers; the 
result was they relapsed, and came again into the hands of the insurance committees. 
In some districts a very large percentage have relapsed. It is clear that a good deal 


BENEFITS. 


23 


of this money has been wasted. This is true if we contemplate, at all events, the 
large number of patients who have gone back again into their ordinary life and their 
previous occupations. Many live in unsuitable homes, and work at occupations 
which put a great strain upon them. At the end of last year we obtained grants from 
the treasury to enable the authorities to provide apparatus and workshops, and the 
rest of it for training purposes as an adjunct to the sanatorium treatment, because a 
great many of these cases can not expect to be able again to follow their former occu¬ 
pations; they can not stand the stress of industrial competition, at least for some 
years. Whilst there are the sanatoriums we have also provided opportunities for 
training in alternative occupations. 

This is a very important ingredient in the treatment, because when a large number 
of patients have been in the sanatoriums for some time, they want to go home, because, 
as they say, “they have got fed up.” One of the reasons is that they have had no 
occupation sufficient to interest them. Where you have a well-developed and 
properly arranged training system established, it is of enormous benefit in its effect, 
and more than that. Where you can have a system whereby men who live in decent 
conditions can pursue an alternative occupation, as they are doing in two or three 
places now very successfully, in a colony village, there you can get a large percentage 
of cases as permanently cured. They help, too, to contribute to their own mainte¬ 
nance. This applies especially to a number of ex-service men who are now under 
treatment and training in this form. It is perfectly clear you can not deal with this 
question unless you have an authority competent to deal with the whole lot of it. It 
is a mistake, I may say in passing, to divide responsibility. Whatever authority you 
may set up—and we are working at it now—it will have to be an authority that will 
take over the charge of the different parts of the health service, certainly including 
that now ordinarily conducted, for the most part, under the poor law. 

A further point here is that members of the insurance committees have gathered, 
as we know, a great mass of experience, and any committee or authority which adminis¬ 
ters these services will have to call to its aid a number of expert persons from outside, 
and to be able to coopt a certain number of persons. We apply that principle in the 
housing bill, and we shall certainly have to apply it in respect to the health services. 
It is a perfectly reasonable thing that when that time comes we should provide that 
members of insurance committees shall be specially nominated and coopted. How¬ 
ever that may be, I accept the principle of securing cooptation on the insurance 
committees. 

Sir John Butcher. I take it this will be a mandatory duty under the new body. 
It will not be optional? 

Doctor Addison. I can not at present give the precise form, but we shall provide 
for the committees acting upon the principle of cooptation. I would not pledge 
myself to the words to be proposed hereafter; but the principle I accept. It will be 
effectively secured in some way. The insurance committees will have a great deal 
to do besides this. The administration of the medical benefit will form a very large 
proportion of the work. There is no question at all of insurance committees going 
out of existence. It is clear that to transfer this obligation of the societies to the 
local authorities we shall require further legislation—which is already in draft; but 
it is also clear—and this I should like to say here and now—that that legislation must 
involve that the local authorities should not be losers by this transference of respon¬ 
sibility. 

Finances of the sanatorium benefit .—Under the 1911 act the in¬ 
surance committees, under the supervision of the commissioners, 
handled all the funds of the sanatorium benefit; later a system of 
special grants for tuberculosis aid was made by Parliament to the 
local authorities and in 1919 the Ministry of Health law placed all 
State sanatorium work for tuberculosis in the control of that office. 
Under the 1911 act the insurance committees were provided annually 
with 15 pence (30.5 cents, par) for each insured person in their 
area out of the benefit moneys of the societies, to which was added 
1 penny (2 cents, par) out of funds provided by Parliament. Later 
the treasury grants were increased and given to the local authorities 
for all tuberculosis cases, including the insured persons (the Hob- 
house grants). In 1920, therefore, the Ministry of Health had 
available for sanatorium benefit of insured persons the 15 pence 


24 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


from the national health insurance fund, a grant from the national 
treasury, and a grant from the local authorities in each area. 

The third report on the insurance system, for 1914-1917, stated 
that up to the end of the year 1917, in 32 out of the 49 counties 
(excluding London) and in 55 out of the 78 county boroughs of 
England, comprehensive agreements were in force between insur¬ 
ance committees and the local authorities, under which were pro¬ 
vided treatment in approved institutions (residential treatment) 
and the services of a dispensary organization for persons in their 
homes, the latter including dispensary treatment, the services of a 
tuberculosis health officer lor examining and reporting on cases, for 
giving expert advice as to treatment, etc. Many of the agreements 
also provided for the services of a visiting nurse. Progress has 
been made in providing institutional facilities in spite of the diffi¬ 
culties which were caused by the war; thus in England in 1914 the 
number of approved dispensaries was 255 and the number of beds 
in approved residential institutions was 9,200; in August, 1917, the 
dispensaries numbered 370 and the beds 11,700. The progress in 
London has been more rapid than that for the rest of the country 
because greater facilities were available. 

At the time of the enactment of the 1911 law, a special appropria¬ 
tion was inserted in the 1911 finance act, which authorized the ex¬ 
penditure of £1,500,000 ($7,299,750, par) for the construction of 
tuberculosis sanatoriums in the four countries, the amount to be 
apportioned on the basis of population. It was stated at the time 
that similar appropriations for the same purpose would be made 
later, but the outbreak of the war postponed such action. 

SICKNESS BENEFIT. 

This benefit is a cash payment provided while the insured person 
is incapable of work by reason of some specific disease or of bodily 
or mental disablement, of which notice has been given. The pay¬ 
ments are made, it will be noted, for inability to work, and not 
because the member has some illness. The disability must be 
proved by the doctor’s certificate, and the benefit is paid until the 
doctor certifies that the member is able to resume work. The 
maximum period of benefit is 26 weeks, beginning with the fourth 
day of incapacity. After the 26 weeks are exhausted, the right to 
disablement benefit begins. 

When a member has received benefit for one illness, and falls ill 
again within 12 months of his recovery, the second illness is regarded 
as a continuation of the first; sickness benefit then begins on the 
first day of the second illness and may continue until 26 weeks’ 
benefit (including those in the first illness) has been paid. 

Qualifications .—A person becomes eligible for this benefit when 
he has been a member of an approved society (or a deposit contribu¬ 
tor) for 26 weeks and 26 contributions have been paid in respect of 
his insurance. As stated later, a lower rate of benefit is paid during 
the first two years of membership. Because a certain amount of 
supervision of the beneficiary is necessary, no benefit is paid while 
the beneficiary is outside of the United Kingdom. 

Under certain circumstances even though these conditions have 
been fulfilled, sickness benefit may be withheld in whole or in part; 
these circumstances include: 


BENEFITS. 


25 


1. When the member is in arrears. 

2. When the member is in receipt of compensation or damages 
in respect of the injury or disease causing the incapacity. 

3. When the member is a discharged sailor or soldier in receipt 
of a pension for disablement in the highest degree. 

4. When the member is an inmate of a workhouse, hospital, etc. 

5. When the member has ceased temporarily or permanently to 
be insured. 

6. When the member is suspended from benefits as a penalty 
under the rules of the society. 

Rates of benefit .—A higher rate of sickness benefit is paid to men 
than to women in order to make the benefit approximate the wage 
loss of the two groups. A circular of the Ministry of Health, issued 
in 1920, gives the following statement of. benefits to be paid after 
July 5, 1920: 

[Shilling at par=24.3 cents; pcnny=2.03 cents.) 

Men. Women. 

s. d. s. d. 

Ordinary rate of sickness benefit. 15 0 12 0 

Sickness benefit until lapse of 104 weeks from entry into insurance, 
and payment of 104 contributions (see section 12(1) of act of 1918). 9 0 7 6 

To show fully the difference in the rates of benefit made by the 1920 
act, the following table compares the old rates with those in force 
after July 5, 1920: 

CHANGES IN RATES OF BENEFIT AND OF CONTRIBUTION INTRODUCED BY THE 

ACT OF 1920. 


[Source: Ministry of Health. Report by the Government actuary upon the financial provisions of the 
national health insurance bill of 1920. London, 1920. Cmd. 612, p. 3. Shilling at par=24.3 cents; 
penny= 2.03 cents.) 


Item. 

Men. 

Women. 

Before 
July 5, 
1920. 

After 

In¬ 

crease. 

Before 

After 

J i& 5 ’ 

In¬ 

crease. 

Benefits: 

s. d. 

s. d. 

s. d. 

s. d. 

s. d. 

s. d. 

Sickness, per week. 

10 0 

15 0 

5 0 

7 6 

12 0 

4 6 

Disablement, per week. 

5 0 

7 6 

2 6 

5 0 

7 6 

2 6 

Maternity. 

30 0 

40 0 

10 0 

30 0 

40 0 

10 0 

Annual charge upon insurance funds toward the cost 







of: 







Medical benefit. 

6 6 

9 6 

3 0 

6 6 

9 6 

3 0 

Sanatorium benefit 1 . 

9 



9 



Weekly contribution: 







Employer. 

3 

5 

2 

3 

5 

2 

Insured person. 

4 

5 

1 

3 

4 

1 

Total. 

7 

10 

3 

6 

9 

3 


1 The withdrawal of the sanatorium benefit from the act is equivalent to the reduction of liabilities by 
9d. (18.3 cents, par) per annum for each insured person. 


The benefits provided by the 1920 act represent an increase in the 
ordinary rate of 50 per cent for men and 60 per cent for women. 
This increase is even greater than these ratios would indicate, because 
the contribution rate has not been increased to quite the same extent. 
The total contribution of the employer and employee was increased 
from 7d. to lOd. (43 per cent) for men and from 6d. to 9d. (50 per 
cent) for women. 

































26 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


At the time the 1920 law was passed a plea was presented for placing 
the women’s benefits at the same rate as the men’s. The Minister of 
Health stated that this matter had been considered, but as such an 
increase of benefit would have to be accompanied by a corresponding 
increase of contribution, it was finally decided to maintain the differ¬ 
ence in rates. 

What might be regarded as a supplementary benefit is the provision 
that no contributions need be paid while the member is in receipt of 
sickness or disablement benefit. 

Benefits while in arrears of contribution .—It frequently happens that 
an employed contributor, on account of unemployment, falls in arrears 
of payment of his dues. In such case the right to benefit does not 
cease at once but the benefits are gradually reduced. As a general 
rule 48 weeks of contribution are treated as a full year’s contribution, 
so that an insured person always has a leeway of four weeks in each 
year. If the unpaid contributions exceed this, then the weekly sick¬ 
ness benefit is reduced by Is. (24.3 cents, par) for each four weeks of 
arrears, with some variation in the case of women’s benefits. As 
already stated, arrears do not accumulate while the member is in 
receipt of sickness benefit. 

In Statutory Rules and Orders No. 1300 of 1921 is given the follow¬ 
ing schedule of reductions in sickness and disablement benefit for the 
various stages of arrears, as well as the “penalty rate,” or “appro- 

E riate sum,” the payment of which will enable an insured person to 
eep himself in full standing. It will be recalled that the ordinary 
rates for employed contributors are: Sickness benefit, men 15s. ($3.65, 
par), women 12s. ($2.92, par); disablement benefit, 7|s. ($1.83, par) 
for men and women alike. The arrears reduction schedule is as 
follows: 

SCHEDULE OF REDUCTIONS IN BENEFIT FOR ARREARS OF CONTRIBUTIONS: EM¬ 
PLOYED CONTRIBUTORS. 

[Source: Statutory Rules and Orders, 1921, No. 1300, national health insurance. Arrears regulations, 1921 

dated Aug. 10, 1921, p. 14.] 


Number of contributions (in¬ 
cluding weeks of sickness). 

Sickness benefit. 

Disable¬ 
ment 
benefit. 
Reduc¬ 
tion of 
rate of 
benefit, 
men 
and 

women. 

The appropriate 
sums to secure full 
benefits. 1 

Men. 

Women. 

Reduc¬ 
tion of 
ordinary 
rate. 

Reduc¬ 
tion of 
rate 
during 
first 2 
years 
of insur¬ 
ance. 

Reduc¬ 
tion of 
ordinary 
rate. 

Reduc¬ 
tion of 
rate 
during 
first 2 
years 
of insur¬ 
ance. 

Men. 

Women. 


s. d. 

s. d. 

s. d. 

s. d. 

s. d. 

s. d. 

s. d. 

45 to 47. 

1 0 

0 6 

1 0 

0 6 

0 6 

1 0 

1 0 

42 to 44. 

2 0 

1 0 

2 0 

1 0 

1 0 

2 0 

2 0 

39 to 41. 

3 0 

1 6 

3 0 

1 6 

1 6 

3 0 

3 0 

38 to 38.... 

4 0 

2 0 

4 0 

2 0 

2 0 

4 0 

4 0 

33 to 35. 

5 0 

2 6 

4 0 

2 6 

2 6 

5 0 

4 0 

30 to 32. 

6 0 

3 0 

5 0 

3 0 

3 0 

6 0 

5 0 

26 to 29. 

7 0 

3 6 

5 0 

3 6 

3 6 

7 0 

5 0 


i Usually called “arrears penalty, 1 
























BENEFITS. 27 


SCHEDULE OF REDUCTIONS IN BENEFIT FOR ARREARS OF CONTRIBUTIONS: VOL¬ 
UNTARY CONTRIBUTORS. 

[Source: Statutory Rules and Orders, 1921, No. 1300, national health insurance. Arrears regulations, 1921. 

dated Aug. 10, 1921, p. 15.] 


Number of contributions (in¬ 
cluding weeks of sickness). 

Reduction of rate 
of sickness bene¬ 
fit. 

Reduc¬ 
tion of 
rate of 
disable¬ 
ment 
benefit, 
men 
and 

women. 

Men. 

Women. 


s. d. 

$. d. 

s. d. 

48 to 49. 

1 6 

1 0 

0 6 

46 to 47. 

3 0 

2 6 

1 6 

44 to 45. 

4 6 

4 0 

2 6 

42 to 43. 

6 0 

5 0 

3 0 

39 to 41. 

7 6 

6 0 

3 6 


In the case of an employed contributor, if the number of contribu¬ 
tions paid is 25 or less, he is suspended from sickness, disablement, 
and maternity benefits during the succeeding benefit year. 

Behavior during sickness .—The latest available regulations for the 
members who are in receipt of sickness or disablement benefit, those 
of April 15, 1919, contain the following provisions: 

(1) A member who is incapable of work and is, or may become, entitled to sickness 
or disablement benefit in respect of the incapacity— 

(a) Shall obey the instructions of the doctor in attendance and shall answer any 
reasonable inquiries by the society as to the instructions given by the doctor; 

(£>) Shall not be absent from his place of residence for the time being between the 
hours [insert such hours of the evening and morning as may be desired. Different 
hours should be inserted for summer and winter], and shall not be absent at any time 
without leaving word where he may be found, provided that the society may, if they 
think fit, exempt the member from the operation of this rule upon such conditions, 
if any, as they may impose; 

(c) Shall not leave the locality where he resides without requesting the consent 
of the society, which consent shall not be unreasonably withheld and shall be deemed 
to have been given unless written notice of objection is given to the member as soon 
as possible after receipt of a notification of his intention to leave the locality; 

(d) Shall not be guilty of conduct which is likely to retard his recovery; and 

le ) Shall not do any kind of work, domestic or other, unless it be light work for which 
no remuneration is, or would ordinarily be payable, or work undertaken primarily 
as a definite part of the member’s medical treatment in a hospital, sanatorium, or other 
similar institution. 

(2) The society may exempt a member from the operation of rule (e) of paragraph 
(1) for such time as they may determine in a case where the member has become 
incapable of following his usual occupation and is undergoing a course of training with 
a view to fitting himself to take up some other occupation. 

Sickness and disablement benefits are paid by the approved society 
of which the beneficiary is a member; in the case of a deposit con¬ 
tributor, they are paid to him by the insurance committee. On the 
production of the doctor’s certificate with the member’s notice of 
sickness, an entry in the books of the society is made by its officials. 
Within eight days thereafter a second certificate must be filed by the 
member and sickness benefit then becomes payable. Each society 
must arrange for a sick visiting service, and usually such a visitor is 
sent to the member on the production of the notice of sickness. The 
benefit is paid at such times as the rules of the society provide and 
in many cases the visitors are used to carry the cash to the benefici¬ 
ary. The benefit must be for fractions of a week and usually these 














28 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


fractions are one-sixth of the weekly benefit. If the member usually 
works on Sundays as well as weekdays, the rules of the society must 
specify the method to be followed; as the law fixes the rate of bene¬ 
fit per week, this point is of minor importance. The benefit is con¬ 
tinued until the doctor gives the so-called final certificate, on which 
the member must fill out the space for “ declaring off.” 

The question of malingering is one which always arises under a 
system of health insurance and one of the duties of the insurance 
authorities is to take steps to correct this evil. The 1914-1917 re¬ 
port of the National Health Insurance Joint Committee (Cd. 8890) 
contains a statement of the methods used by the Scottish commis¬ 
sion. The report (p. 116) states: 

The “claims experience” of societies in Scotland is kept under constant observation. 
As soon as the necessary information is available for each year, the rates of expenditure 
are worked out, and inquiry is made in any case in which these rates appear to be ex¬ 
cessive. In addition, each society, when applying for funds, is required to furnish a 
statement showing its expenditure on cash benefits and on administration up to the 
last possible date, and from the information thus supplied the commission judge 
whether the society’s rate of expenditure during the year then current is abnormal. 
If a society is found to be experiencing an exceptionally heavy drain on its benefit 
funds, special inquiry is made into the circumstances. These special inquiries have 
generally been followed by a meeting with the executive and officials of the society 
concerned, when their methods of administration were fully discussed and suggestions 
made for preventing depletion of the funds by improper claims. The principal sug¬ 
gestions made at these meetings might be grouped under three heads, viz: (1) Careful 
scrutiny of claims and of medical certificates; (2) sick visitation; and (3) use of 
medical referees. 

In most cases the reports of the sick visitors are considered a 
sufficient check on the validity of the claim for sickness and disable¬ 
ment benefits. Where the officials of the society have reason to be¬ 
lieve that the period of benefit is being unduly prolonged, the services 
of a “medical referee” are called for, to prevent malingering. These 
referees are usually paid out of the society’s administration expense 
account. 

Some of the societies have made agreements to provide a joint 
service of sick visitors and medical referees. In certain areas, such 
as London, medical referees have been appointed with the coopera¬ 
tion of the insurance committee, each case examined being paid for 
on a fee basis; in London the examination costs 7s. 6d. ($1.83, par) 
per case, one-third of which is charged to the society and the remainder 
is paid for by the committee. In Bristol the medical practitioners 
made it a condition of accepting service under the act that a medical 
adviser should be appointed whose sole duty should be to pass on 
doubtful cases of incapacity for work. The plan of having medical 
advisers for the various regions has been under discussion since 1914, 
and it is the intention of the Ministry of Health to appoint such 
officers as rapidly as conditions permit. These officers are to be 
full-time medical officers, whose duty is principally that of acting 
as referee in doubtful cases; they also advise on courses of treatment, 
etc., when requested by the practitioners themselves. Their cooper¬ 
ation with the insurance doctors is expected to aid in the maintenance 
of an efficient medical service for insured persons. 

The appointment of the regional medical staff and other measures 
are evidence that the administrative officials are alive to the need of 
watchfulness in regard to malingering, always present in both State 
and private insurance. 


BENEFITS. 


29 


DISABLEMENT BENEFIT. 

The disablement benefit is payable in case of incapacity which 
continues after the 26 weeks of sickness benefit are exhausted and 
continues as long as the incapacity lasts, but ceases at the ag£ of 70. 
It is, therefore, an allowance for invalidity following the sickness 
benefit, and if necessary is continued until the old-age pension 
begins. 

Qualifications .—The number of weeks which must have elapsed 
since the member’s entry into insurance is 104, and 104 contributions 
must have been paid. 

As in the case of sickness benefit, it is open to an insured person, 
who is unemployed or ill, to qualify for disablement benefit by paying 
up the necessary arrears himself. The rate at which these contribu¬ 
tions should be paid is the same as in the qualification for sickness 
benefit. This qualification is, however, not retrospective in its effect; 
that is, the payment of contributions making up the number neces¬ 
sary for qualification will not entitle an insured person to sickness or 
disablement benefit for a period prior to the date of such payment. 
Thus if a person has paid no contributions for 13 weeks he may secure 
full benefits for the 13 weeks by paying the arrears penalty (see p. 26), 
but he may secure sickness or disablement benefit after the date of 
his payment. 

In general, the other details of right to disablement benefit are the 
same as for sickness benefit. 

Rate of benefit .—The benefit is the same amount for men and women 
alike. Payment begins the day after sickness benefit is exhausted 
and continues as long as the member is rendered incapable of work 
by a specific disease or bodily or mental disablement. It is a weekly 
payment of 7s. 6d. ($1.83, par)—that is, one-half of the maximum 
sickness benefit. 

In case of arrears of contribution, the benefit is reduced by 6d. 
(12.2 cents, par) for each four weeks of arrears. The table on page 26 
shows the benefit rates and the arrears penalty rates for men and 
for women. 

The rates just given are those provided by the act of 1920; before 
the passage of that act the rates were 5s. ($1.22, par) per week for 
men and women alike. The new law thus increases the benefit by 
50 per cent. 

MATERNITY BENEFIT. 

General features .—One of the most involved features of the insur¬ 
ance system is the maternity benefit. Briefly stated, it is a lump¬ 
sum payment of either 40 or 80 shillings ($9.73 or $19.47, par) on 
the birth of a child. Prior to 1920 the amount of benefit was 30 or 
60 sh illin gs ($7.30 or $14.60, par). The 40-shilling benefit is paid in 
respect of a man’s insurance, the benefit being the property of his 
wife. The 80-shilling benefit is paid to an insured married woman, 
though this statement is not entirely complete, as will be explained 
later. The benefit does not include medical attendance, and sick¬ 
ness benefit may not be paid for the four weeks following the date of 
childbirth unless the sickness is due to a cause not connected, directly 
or indirectly, with the confinement. 

104936°—23—Bull. 312-3 


30 NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 

In explaining the reason for including the maternity benefit, Mr. 
Lloyd George made the following statement: 

We have a provision for maternity, an allowance of 30 shillings, which I think is 
one of the most valuable provisions in the bill, and we are going to see that the money 
is spent £pr the purpose for which it is designed, in spite of one or two protests we have 
had from friendly societies. The money is meant for the mother, to help her in dis¬ 
charging the sacred function of motherhood by proper treatment, fair play, so as to 
put an end to the disgraceful infantile mortality of this country. 2 

Great Britain, like a number of the States of the United States, 
had prohibited the employment of women in industrial establishments 
for a period of four weeks after childbirth, and this law, enacted in 
1891, is still in force. One of the main arguments against such a 
law is the fact that it prevents a wage-earning mother from securing 
an income at a period when her expenses are higher than usual, and 
does this in her own and the child’s interest, but at the same time it 
offers no substitute. It was hoped to ameliorate this condition by 
the provision of the maternity benefit and by making its payment 
conditional on the beneficiary abstaining from remunerative employ¬ 
ment for a period of four weeks. 

The law originally intended that the mother should have the 
woman’s sickness benefit of 7s. 6d. ($1.83, par) for a period of four 
weeks following confinement, making 30s. ($7.30, par) for the period. 
This amount had been used as a childbirth benefit for a long period 
of years by the Hearts of Oak Friendly Society, and was therefore a 
benefit to which the members of friendly societies were accustomed. 
The amount of 30s. benefit is smaller that that provided by the 
German insurance code of 1911 (half wages for eight weeks, with 
additional nursing benefit) and the French law of 1913 (one-half to 
1 i francs (9.7 to 29 cents, par) daily for eight weeks, with additional 
nursing benefit), but this comparison is of course no longer valid in 
view of the increase in benefit to a possible 80 shillings ($19.47, par). 

Waiting period and other qualifications .—Prior to July 1, 1918, the 
maternity benefit became available after a waiting period of 26 weeks, 
but the law of 1918 changed this to 42 weeks, or approximately 10 
months. The departmental committee on approved society finance 
and administration in its report of 1916 (Cd. 8396) had recommended 
that the period be made 52 weeks for both male and female members, 
in order to prevent any exploitation of this feature of the insurance, 
but Parliament reduced this term to 42 weeks. 

The insured woman’s benefit carries with it the obligation to abstain 
from remunerative work for a period of four weeks after the date of 
childbirth, with the penalty of a fine for infraction of this rule. 
Every approved society and insurance committee is required to estab¬ 
lish rules on this subject, and these rules must be ratified by the 
higher insurance authorities. 

The second 40-shilling benefit, paid by the wife’s society, is not 
subject to the qualifications attached to the payment of the sickness 
benefit; that is, it may be payable even though the woman member 
has been suspended from sickness benefit on account of arrears or 
has already exhausted the full 26 weeks for which sickness benefit 
is payable. Similarly, the payment of the second maternity benefit 
will not count as the payment of four weeks’ sickness benefit for the 
purpose of determining when the right to 26 weeks’ sickness benefit 


* The People’s Insurance, by David Lloyd George. London, 1912, p. 183. 



BENEFITS. 


31 


1 l ? X ^ aUS ^ e d‘ th e same manner, if the father dies before the 
child is born, his insurance is regarded as having continued up to the 
date of confinement and the fact that his dues have not been paid 
after his death is disregarded. 

As the insured married woman generally receives 40s. of the 80s. 
benefit from her husband’s society, it was necessary to make pro¬ 
vision that the maternity benefit should be paid even if the husband 
was in arrears or for other reasons disqualified in his membership 
rights; otheftvise the wife would be in a less favorable position than 
if her husband was not insured at all. It was provided, therefore, 
that when the insured husband is disqualified, the wife’s society 
must pay the entire 80s. 

To obtain the maternity benefit in respect of the husband’s 
insurance, proof of marriage in the form oi a marriage certificate 
must be produced, and in the same way the wife’s society must have 
similar proof before paying the second 40s. benefit. One benefit may 
be paid by the wife’s society without the certificate, since an insured 
woman is entitled to the benefit even if not married. These certifi¬ 
cates are supplied by the registrar at a cost of Is. (24.3 cents, par). 

If an insured woman gives up her employment on marriage, she 
retains her right to the maternity benefit for two years from the date 
of ceasing to be an employed contributor. 

An insured woman is required to give formal notice of her mar¬ 
riage, to her society within eight weeks of the date thereof; if the 
society has not been so notified and pays to her benefits to which she 
is not entitled, it may deduct the excess amount so paid from the 
amount of any benefit subsequently payable to her. 

Rate of benefit .—The basic amount of the maternity benefit, nrior 
to July, 1920, was 30s. ($7.30, par); the act of 1920 raised this to 
40s. ($9.73, par). It is paid in respect of a man’s insurance and is 
the wife’s property. If the wife is also an employed contributor, 
then her insurance entitles her to another lump-sum payment of 40s. 
from her society, making 80s. ($19.47, par) in all. Husband and 
wife may, and often do, belong to the same society. 

As a rule, the husband of an insured wage-earning woman will 
also be an insured person; to simplify the matter, the law provides 
that an insured married woman shall have 80s. regardless of whether 
her husband is insured; if he is not insured, or if insured is not quali¬ 
fied for some reason (arrears, etc.), the wife’s society pays the entire 
80s. 

An unmarried insured woman is entitled to a maternity benefit 
of 40s. ($9.73, par) from her society. 

What may be regarded as a supplementary benefit is the provision 
of section 10 (4) of the act of 1911, under which no account is taken 
of arrears of contributions accruing during the two weeks before and 
the four weeks after the date of childbirth in the case of a married 
woman who is herself insured. Such a member is therefore exempt 
from the payment of dues for a period of six weeks. 

To show the relation of the husband’s society and the wife’s 
society in respect to the payment of the maternity benefit, the official 
Handbook for Approved Societies gives the following schedule. 
This volume was published in 1915 and the rates therefore are not 
now in use, but the schedule illustrates the relation between the two 
societies. 


32 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


SCHEDULE OF OBLIGATIONS OF APPROVED SOCIETIES OF GREAT BRITAIN FOR 
BENEFITS UNDER NATIONAL INSURANCE ACTS, IN RESPECT OF INSURED MAR¬ 
RIED MEMBERS. 

[Source: Great Britain, national insurance acts. Handbook for the Use of Approved Societies. English 
edition, London, 1915, pp. Ill, 112. The benefits shown in this schedule are not now in use.] 

Part I. For use by husband's society. 


A. Husband insured, and qualified for benefit. 

B. Husband insured, but not qualified for benefit.. 


Husband’s society pays 30s. ($7.30) if husband is a 
British subject, or if wife was before marriage a 
British subject; £1 3s. 4d. g&$5.68) if he is an 
alien and his wife was before marriage an alien. 
Husband’s society pays nothing. 


Part II. For use by wife’s society. 


A. Wife an employed contributor, but not qualified 

for benefit. 

B. Wife an employed contributor and qualified for 

benefit. f 
Then, if— 

(1) Husband is also insured, and qualified.. 


(2) Husband is also insured, but not quali¬ 

fied. 

(3) Husband is not an insured person. 


(4) Husband is a deposit contributor, but 
the amount standing to his credit is 
not enough to provide full benefit; 
i. e., 30s. ($7.30) or £1 3s. 4d. ($5.68), 
as above. 


Wife’s society pays nothing. 


Wife’s society pays 30s. ($7.30), or 18s. ($4.38) if 
husband is an alien and wife was an alien before 
marriage. 

Wife’s society pays 60s. ($14.60), or 36s. ($8.76) if 
husband is an alien and wife was an alien before 
marriage. 

Wife’s society pays 60s. ($14.60), or 36s. ($8.76) if 
husband is an alien and wife was an alien before 
marriage. 

Wife’s society pays— 

If the husband is a British subject, or if the wife 
was before marriage a British subject, 30s. 
($7.30) at once, and, when they know the sum 
available from the husband’s credit, so much 
more as will, together with that sum, make up 
a further 30s. ($7.30). 

If the husband is an alien, and the wife was be¬ 
fore marriage an alien, 18s. ($4.38) at once, and, 
when they know the sum available from the 
husband’s credit, so much more (if any) as is 
required, together with that sum, to make up 
a further 18s. ($4.38). 


ADDITIONAL BENEFITS. 

With the approval of the Ministry of Health, the benefits just 
described may be increased or certain other benefits, called “addi¬ 
tional” benefits, may be provided by an approved society. This 
approval is conditional on the financial status of the society, and as 
the results of the first valuation have not yet been completely deter¬ 
mined these additional benefits have not yet been provided. For 
such societies as show a surplus, authority is given to provide the 
benefits specified. 

The list of these benefits is given in the fourth schedule of the act 
of 1911. Section 37 of that act provides that no surplus or part of a 
surplus of a society shall be used for a death benefit and that only 
the benefits indicated in the following list shall be provided: 

1. Medical treatment and attendance for any persons dependent upon the labor 
of a member. 

2. The payment of the whole or any part of the cost of dental treatment. 

3. An increase of sickness benefit or disablement benefit in the case either of all 
members of the society or of such of them as have any children or any specified number 
of children wholly or in part dependent upon them. 

4. Payment of sickness benefit from the first, second, or third day after the com¬ 
mencement of the disease or disablement. 

5. The payment of a disablement allowance to members though not totally incapable 












BENEFITS. 


33 


6. An increase of maternity benefit. 

7. Allowances to a member during convalescence from some disease or disablement 
in respect of which sickness benefit or disablement benefit has been payable. 

8. The building or leasing of premises suitable for convalescent homes and the 
maintenance of such homes. 

9. The payment of pensions or superannuation allowances whether by way of addi¬ 
tion to old-age pensions under the old age pensions act, 1908, or otherwise. 

10. The payment, subject to the prescribed conditions, of contributions to superan¬ 
nuation funds in which the members are interested. 

11. Payments to members who are in want or distress, including the remission of 
arrears whenever such arrears may have become due. 

12. Payments for the personal use of a member who, by reason of being an inmate 
of a hospital or other institution, is not in receipt of sickness benefit or disablement 
benefit. 

13. Payments to members not allowed to attend work on account of infection. 

14. Repayment of the whole or any part of contributions thereafter payable under 
Part I of this act by members of the society or any class thereof. 

15. Such other additional benefits being of the same character as any of those 
hereinbefore mentioned as may be prescribed. 

Section 15 of the act of 1920 authorized the National Health 
Insurance Joint Committee to specify the form of the benefits to be 
allowed under the terms of clause 15 above. In February, 1921, the 
following draft of an order was published as indicating the views of 
the insurance authorities. Under this order the schedule quoted 
above would have added to it the following: 

15. The payment of the whole or any part of the cost of maintenance and treatment 
of members in a hospital or convalescent home, and the payment of part of the travel¬ 
ing expenses incurred by members in traveling to or from the hospital or convalescent 
home. 

16. The payment of the whole or part of the cost of medical and surgical appli¬ 
ances, other than those provided as part of medical benefit. 

17. The payment of the whole or any part of the cost of optical treatment and 
appliances. 

18. The payment of the whole or any part of the cost of the provision of nurses for 
members. 

The preliminary report on the first valuation, referred to later in 
the description of the actuarial aspects of the system, states that “ in 
the case of a large number of insured persons the disposable surplus 
permits of an additional sickness benefit of 5s. [$1.22, par] a week 
with corresponding additions to the other money benefits.” It 
seems clear, therefore, that in the near future the great majority of 
insured persons will receive additional benefits under one or more 
of the clauses given above. 

MISCELLANEOUS BENEFIT FEATURES. 

Mercantile marine .—Because of special conditions prevailing in 
certain industries only reduced benefits are paid and correspondingly 
lower contributions required. Thus a seaman must be maintained 
by the shipowner while the man is disabled, and medical attendance 
must be provided. During such incapacity the society of which the 
seaman is a member pays him no sickness benefit; the society also 
does not count any such sickness in computing the 26 weeks for which 
benefit may be paid. The contributions are 8d. and 7d. (16.2 cents 
and 14.2 cents, par) for men and women, respectively. 

If, however, the seaman has dependents and his employer is not 
liable for wages, the society may pay the sick benefit in whole or in 
part to the dependents. 


34 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


Married women .—The provisions relating to an insured woman 
who marries and gives up her employment are rather involved and 
arise partly from the fact that her contributions have established a 
certain credit to her account and partly from the desire of the law¬ 
makers to give her special advantages. The woman member must 
give notice of her marriage within eight weeks and her society will 
then provide her with a special circular specifying her rights. The 
general rule is that as soon as a married woman has been out of em¬ 
ployment for eight weeks in the year following the date of her mar¬ 
riage she is automatically transferred to the special married women’s 
class, “ Class K.” When an insured woman keeps on with her 
remunerative employment for a year after marriage, but then 
becomes “unemployed” within the terms of the law, she is treated 
as the usual contributor and is given the “free year” described 
below. 

The special benefits to which “Class K” women are entitled are 
as follows: 

1. Sickness benefit, subject to the normal conditions as to proof of 
inability to work, for six weeks during the year following the date of 
giving up work. The 1920 act uses the words “sickness or disable¬ 
ment benefit” and the rate is made 7s. 6d. ($1.83, par) weekly 
instead of the 5s. ($1.22, par) provided by the 1918 act. If the 
member is entitled to disablement benefit, she may therefore receive 
it for the full six weeks even if she has already exhausted her right 
to sickness benefit. 

2. Maternity benefit of 40s. ($9.73, par) on her first confinement 
after marriage, if it occurs within two years after the date of mar¬ 
riage; this is additional to any benefit she may receive in respect of 
her husband’s insurance. 

3. Medical benefit for one year from the date of her transfer to 
“Class K” plus the period up to either June 30 or December 31 
following the end of the year, whichever comes first. 

The u firee year's ” benefit .—Under the 1918 act the position of a 
person who has ceased to be insured is as follows: He will remain an 
insured person in exactly the same position as he was at the time he 
ceased to be insured for a period of one year. If he was in full stand¬ 
ing, all the benefits must be paid him; if he was in arrears, the 
reduced benefits must be paid him, though of course he is entitled 
to medical benefit in full. This is usually referred to as the “free 
year’s insurance.” It is applicable regardless of the cause of ceasing 
to be an employed contributor, whether it is due to inability to find 
work, increase of income beyond the £250 ($1,217, par) limit, taking 
up employment not included under the laws, etc. 

After this year has expired anyone who later desires or is required 
to enter insurance again is treated as if he were an entirely new 
applicant—e. g., his benefits are smaller for the first 104 weeks, he 
must comply with new waiting periods, etc. 

The voluntary contributor whose employment is not manual and 
whose income exceeds £250 ($1,217, par) is not entitled to medical 
benefit. 

Inmates of institutions .—A person who is an inmate of any work- 
house, hospital, asylum, convalescent home, sanatorium, or similar 
institution, supported by public funds or by charitable contributions, 


SOURCES OP INCOME. 


35 


may not receive benefits directly. Instead, these may be paid to his 
dependents, or if he so authorizes, be paid for his benefit, as for the 
rent of his house, or be paid with his consent to the institution. If 
there is a balance after these possible payments have been made, 
it is paid to him on leaving the institution. 

SOURCES OF INCOME. 

The means for defraying the cost of the insurance system are 
secured from three sources—first, contributions of the insured 
person; second, contributions of the employer of the insured person; 
third, grants from the national treasury. 

For the great majority of the insured persons, the “ employed 
contributors,” the weekly rate of contribution is now lOd. (20.3 
cents, par) for men and 9d. (18.3 cents, par) for women. In the case 
of men the insured person and his employer each pays half; in the 
case of women the insured person pays four-ninths and her employer 
pays five-ninths. The employer thus pays the same amount in both 
cases, so that as far as the insurance is concerned there is no reason 
for the employer to prefer women as against men. In the case of 
insured persons receiving low wages—less than 4s. (97.3 cents, 
par) per day—the employer’s proportion is even higher. 

When the act of 1911 came into force the men’s rate at that time 
of 3d. (6.1 cents, par) for the employer might be taken, on a rough 
approximation, as 1 per cent of wages. Thus the Abstract of Labor 
Statistics, seventeenth issue, published in 1915, gives on pages 48 
to 63 a large number of rates of wages ranging from 20s. to 50s. 
($4.87 to $12.17, par) per week. If 25s. ($6.08, par) be rather 
arbitrarily assumed to be one of the most frequent rates, this would 
make the proportion about 1 per cent of wages for the employer 
and 1J per cent for the insured man. 

GOVERNMENT GRANTS. 

The amounts provided by the National Government fall under two 
heads. In the first place, the Government adds two-ninths to each 
contribution paid in respect of an insured person, men and women 
alike. Secondly, the Government makes a number of appropriations 
for specific purposes, which will be described later. The proportion 
of the total income which the Government pays is very difficult to 
state; but if one is permitted to make a very crude estimate, it may 
be placed at 25 per cent, though even this statement is made with 
many reservations. 

The second group of grants from the national treasiny will be 
described in connection with the financial administration of the 
system. In general these are: For purposes of the medical benefit, 
about £3,100,000 ($15,086,150, par) in 1919; for the women’s 
equalization fund, to defray extra expenditure caused by disability 
due to childbearing, etc., about £280,000 ($1,362,620, par); for the 
central fund, to meet abnormal rates of sickness, £150,000 ($729,975, 
par). The actuaries who prepared the estimates of expenditure for 
benefits under the 1920 act expressed the opinion that the national 
appropriations would defray slightly over 25 per cent of this expendi¬ 
ture, without including any sums for sanatorium benefit. 


36 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


CONTRIBUTIONS. 

The contributions are weekly dues paid jointly by the employer 
and the insured person. By far the greater part of the insured popu¬ 
lation pay at the so-called ordinary employed rate; in the effort 
to adjust the system to the conditions prevailing in certain occupa¬ 
tions or industries special rates of contribution are provided for 
these groups. Except in the case of the merchant marine these 
rates are of minor importance as far as the number of persons insured 
under them is concerned. 

Contributions are not paid during the receipt of sickness or disable¬ 
ment benefit and, in the case of women, during receipt of maternity 
benefit. 

If, however, an employee holds a certificate of exemption from 
insurance, his employer must nevertheless pay the contribution which 
would have fallen to his share had the employee not been exempt. 

Ordinary rate. —Under the act of 1920, the total ordinary employed 
rate of weekly contribution for both employer and employee is lOd. 
(20.3 cents, par) for men and 9d. (18.3 cents, par) for women, the 
employer paying 5d. (10.1 cents, par) of these amounts in each case, 
the male employees 5d., and the female employees, 4d. (8.1 cents, par). 

Low-wage earners. —In certain employments, where the rate of 
wages is lower than that of the great majority of insured persons, a 
special system of contributions is provided. As the law states it: 

In the case of employed contributors of either sex, of the age of 18 or upward, 
whose remuneration does not include the provision of board and lodging by their 
employer, and the rate of whose remuneration does not exceed 4s. (97.3 cents, par) 
a working day, the following shall be the rates of contribution: 

Where the rate of remuneration does not exceed 3s. (73 cents, par) a working day— 

To .be paid by the employer—for men, lOd. (20.3 cents, par) a week; for women, 
9d. (18.3 cents, par) a week. 

Where the rate of remuneration exceeds 3s. but does not exceed 4s. (97.3 cents, par) 

a working day— 

To be paid by the employer, 6d. (12.2 cents, par) a week. 

To be paid by the contributor—men, 4d. (8.1 cents, par) a week; women, 3d. 
(6.1 cents, par) a week. 

These rates for low-wage earners are a distinct modification of the 
rates existing prior to July 5, 1920. Under the act of 1911 the low- 
wage earners were men earning 2s. 6d. (60.8 cents, par) per day or less 
and women earning 2s. (48.7 cents, par) a day or less—both being 
21 years of age or over. The rates for these groups were: 

Weekly rates for low-wage earners prior to July 5, 1920. —Group 
I (wage not exceeding Is. 6d. (36.5 cents, par) per working day): 
The employer paid 6d. (12.2 cents, par) for men, 5d. (10.1 cents, par) 
for women, and Parliament provided Id. (2 cents, par) in each case. 
The insured paid nothing. 

Group II (remuneration over Is. 6d. but not exceeding 2s. (48.7 
cents, par) per working day): The employer paid 5d. for men and 4d. 
(8.1 cents, par) for women, the insured paid Id. in each case, and 
Parliament provided Id. in each case. 

Group III (remuneration over 2s., but not exceeding 2s. 6d. 
(60.8 cents, par) per working day): The employer paid 4d. (8.1 
cent*, par) for men, 3d. (6.1 cents, par) for women, while the insured 
paid 3d. in each case. For the women these rates were the same as 
the ordinary employed rates. 


SOURCES OF INCOME. 


37 


Mercantile marine. —The position of men and women employed in 
the mercantile marine (seamen) is affected by the navigation laws, 
which require the shipowner to provide sickness care and maintenance 
during service on board ship. The contributions to be paid in the 
case of “foreign-going” seamen are*2d. (4.1 cents, par) less than the 
rates for the usual employed contributors—that is, the employer and 
the seaman each pay Id. (2 cents, par) less. 

The men and women employed in coastwise trade (“home trade”) 
are practically in the position of regular contributors. 

Special groups .—Persons who are in the service of more than one 
employer m any calendar week have their contributions paid by the 
first employer of the week. In the case of persons who take home 
work to be done (“outworkers”), the insurance authorities may per¬ 
mit contributions to be paid on the basis of work actually done, and 
for this purpose they have issued a long series of regulations applying 
to specific trades and to particular localities. The usual method is 
for the employer to fill out a blank form giving information as to the 
industry, the employee, etc.; if this statement is satisfactory permis¬ 
sion is granted to pay contributions for each “unit of work” instead 
of for each week oi employment. 

Persons intermittently employed must have employment for at 
least 40 weeks a year for every two successive years in order to main¬ 
tain their status as employed contributors. They may not retain 
their membership by paying the ordinary “ arrears penalty,” but must 
have themselves enrolled as voluntary contributors and pay the full 
rate if their employment is less than the 40 weeks because of such 
intermittent employment. 

It will be noted that the rates of contribution are level or “flat” 
rates—that is, uniform for all persons in a group regardless of their 
ages. The plan used in some insurance systems of making the rates 
a percentage of wages was not adopted for the British system. 

ARREARS. 

The schedule on page 26 shows the rate of reduction of sickness 
and disablement benefit while the member is in arrears of contribu¬ 
tion. The system provides for a special plan of payments by the 
member to restore himself to full benefit; this plan, however, restricts 
the right to temporary periods of genuine unemployment, and a mem¬ 
ber who is in an intermittent employment, or who frequently takes 
up temporary employment, may not receive the advantage of this 
special rate. 

The original plan for extinguishing arrears permitted the insured 
person to retain his full rights by paying his own share (but not his 
employer's) of the regular contribution. Under the act of 1918 this 
right was withdrawn, and since 1918 a system of lump-sum payments, 
entitled “arrears penalty,” has been in use. The amount of these 
cash payments is given in the table on page 26. These payments 
amount in the case of men to Is. (24.3 cents, par) for each four weeks 
of arrears; as the man's contribution is 5d. (10.1 cents, par) per week, 
four weeks' payments would be 20d. (40.6 cents, par), so that the Is. 
payment means a substantial reduction in such cases. For women, 
the arrears penalty is 6d. (12.2 cents, par) for each four weeks, mak¬ 
ing the advantage even greater. 


38 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


The arrears for any contribution year are extinguished in the cor¬ 
responding benefit year, even though no benefit is paid, so that the 
member makes a fresh start each year. Each member’s account is 
made up at the end of each contribution year; contribution cards are 
issued the first part of January and the first part of July, and each 
year begins with the first Monday in July. As stated before, full 
benefits are payable if not less than 48 contributions .are credited for 
the contribution year. When the number paid falls short of 48, the 
member is liable to suffer reduction or suspension of benefits for the 
whole of the following benefit year unless he pays within the so-called 
“ period of grace ” the arrears penalty already referred to. The period 
of grace ordinarily runs to the end of October after the close of the 
contribution year. 

FINANCIAL ADMINISTRATION. 

ACTUARIAL BASIS OF THE SYSTEM. 

The basis used in computing the rates of contribution for defraying 
the cost of the sickness and disablement benefit w~as the experience 
of the Manchester Unity of Odd Fellows, 1893-1897. This is the 
largest of the English friendly societies, and includes a wide variety 
of occupations among its members. The actuaries employed by the 
Government weighted the data of this body of experience to make it 
conform to the characteristics of the general population; the factors 
requiring adjustment were the occupational, the age distribution, the 
marriage rate, the birth rate, etc. The Manchester Unity experience, 
as tabulated, included only male lives, and in the absence of any 
reliable information as to women’s experience, the actuaries decided 
to use the figures for male lives in establishing the women’s rates of 
contribution, though the men’s rates were “loaded” to protect the 
funds. Later experience proved, however, that the loading had not 
been sufficient to carry the higher cost of women’s benefits. 

To verify the elaborate tables of the Manchester Unity experience 
the following comparison was made of the sickness rates of a number 
of friendly societies for periods prior to the year 1900. 

COMPARISON OF RATES OF SICKNESS AMONG MALES AS SHOWN BY VARIOUS 
EXPERIENCES. 

[Source: Report of the actuaries in relation to the scheme of insurance against sickness, disablement, etc., 
embodied in the national insurance bill, 1911. London, 1911. Cd. 5681, p. 15.] 


Age group. 

Weeks of sickness per annum per member. 

-a 

Manchester 

Unity, 

1866-1870. 

Ancient 
Order of 
Foresters, 
1871-1875. 

Friendly 

societies, 

1876-1880. 

Manchester 

Unity, 

1893-1897. 

10 to 19. 

0.54 

1.04 

0.88 

0.92 

20 to 24. 

.75 

.82 

.85 

.90 

25 to 29. 

.81 

.85 

.87 

.95 

30 to 34. 

.93 

.97 

1.02 

1.06 

35 to 39. 

1.06 

1.15 

1.24 

1.27 

40 to 44. 

1.26 

1. 37 

1.47 

1.58 

45 to 49. 

1.64 

1.71 

1.89 

1.99 

50 to 54. 

2.22 

2.27 

2.39 

2.75 

55 to 59. 

3.05 

3.21 

3.36 

4.02 

60 to 64. 

4. 72 

4.59 

5.17 

6. 31 

65 to 69. 

7.24 

7.97 

8.73 

10.59 






















FINANCIAL ADMINISTRATION. 


39 


The actuaries place special emphasis on the fact that for practically 
the whole period for which information is available, there had been 
a steady increase in the average rate of sickness. As their report 
expresses the matter: 

An important result of this investigation was to show that a steady increase in the 
average rate of sickness among male lives at all ages had been taking place for many 
years previously. (Cd. 5681, p. 15.) 

In the report of the operations of the system for 1913-14 (Cd. 
7496, p. 60) this point is again referred to in another aspect: 

It would appear from statements that have been made that the rate of sickness 
among the older friendly societies has risen considerably since the act came into 
operation, and that material excess over the provision made for the sickness claims 
in the voluntary contributions and reserves of the societies is being experienced. On 
the act side, however, the claims on the majority of these societies appear on the 
whole to be within the actuarial provision. 

Apparently any system of health insurance, whether State or pri¬ 
vate, must include this factor as an element of cost in computing its 
income. According to the latter of the above quotations, the private 
insurance system had experienced the usual increase in cost, while in 
the State system it had not yet come into operation. 

On the basis of the Manchester Unity tables, a system of flat rates 
or level premiums was worked out and was applied to the whole 
insured membership. If such a flat-rate schedule of charges is placed 
on the whole number of insured persons, the inequalities of occupa¬ 
tional, age, sex, etc., risks will be of slight importance because of the 
operation of the law of average; the favorable and the unfavorable 
factors together will produce an aggregate result which in a large 
number of cases can be readily approximated. The essential point 
to be emphasized is that such a flat-rate system needs as carriers 
organizations containing large numbers of persons with a wide 
variety of risks in order to equalize these variations. 

The plan adopted for the organization of the carriers of the British 
system, however, did not comply with this requirement. The in¬ 
sured persons were permitted, and in fact encouraged, to segregate 
themselves into societies which in many cases were comparatively 
small in numbers and which did not contain a variety of risks—many 
of them even concentrated good or poor risks in one group, as in the 
case of certain trade-unions. Thus it was well known that certain 
groups of agricultural workers had rates of sickness much lower than 
the average, while other groups, such as miners, had rates in excess 
of the computed average. The trade-union societies, for instance, 
have recommended that plans be prepared for the nationalization of 
assets and liabilities “ to secure for unhealthy and dangerous occupa¬ 
tions the full benefits of national health insurance.” 3 

Under this system of flat-rate contributions, with the membership 
divided into groups which do not afford an equal distribution of risks, 
there are four factors to be provided for, in order to secure some 
measure of equalization: 

1. The age distribution of the membership; this is cared for by the 
system of “reserve values.” 

2. The probability of an excess of liabilities, or deficiency on valua¬ 
tion, of a society due to expenditures for benefit being in excess 
of the expected; this is provided for by the contingencies fund. 


a The National Insurance Gazette. London. February 7, 1920, p. 68. 



40 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


3. The probability of a deficiency on valuation caused by abnormal 
rates of sickness due to the nature of the occupation of the members, 
or the environment in which they live, or an epidemic such as in¬ 
fluenza, or some other cause beyond the control of the society; this 
is provided for by the central fund. 

4. The fact that women, especially married women, have a high 
rate of disability, principally on account of childbearing. This is 
cared for by the women’s equalization fund. 

RESERVE VALUES. 

The earliest age of admission to the insurance is 16, and as all 
persons over this age pay the same contributions, there is danger 
either of loss to the system or of making the younger ages pay the 
benefits of the older. To obviate this danger, the system called 
“reserve values” has been created and a set of tables prepared to 
show the capital sum which must be provided to meet the loss on 
the benefits of the ages over 16. 

Whenever a person of the age of 17 or over joins a society the min¬ 
istry at once makes to that society a theoretical loan—in other 
words, gives it a credit—of an amount equal to the capital sum 
stated in the reserve values table to be necessary to offset the loss 
caused by the higher age of that member. This credit involves the 
payment by the society of 3 per cent interest. 

The credit is to be redeemed by having the authorities withhold 
from each weekly contribution a certain sum which will pay the inter¬ 
est and eventually cancel the capital sum. Originally it was expected 
that the reserve values would be repaid by 1932, but later changes 
have postponed this date to about 1955. 

Under the act of 1920 the amount of the weekly contributions to 
be applied to the reserve values fund (or sinking fund, as it is fre¬ 
quently called) will be ljd. (2.7 cents, par) in the case of men and 
l^d. (2.9 cents, par) in the case of women. It is estimated that these 
deductions will be sufficient to complete the redemption in about 35 
years from 1920. In 1912 the amount of the reserve values to be re¬ 
deemed was placed at £87,000,000 ($423,385,500, par); in July, 1920, 
the unredeemed reserve values were about £65,000,000 ($316,322,500, 
par). The law of 1920 added about £45,000,000 ($218,992,500, par) 
to the reserve values, making the total about £110,000,000 ($535,- 
315,000, par). Under the rates of deductions provided by the 1920 
law, the aggregate income available in the first year will amount to 
about £4,800,000 ($23,359,200, par), of which £3,300,000 ($16,059,- 
450, par) will be required for interest, leaving £1,500,000 ($7,299,750, 
par) for reduction of the principal. 

The history of these deductions is of interest. The act of 1911 
provided that the rates of deduction should be, in the case of men, 
lfd. (3.2 cents, par); in the case of women, ljd. (3 cents, par). 
These deductions it had been estimated would redeem the reserve 
values in about 18 years. The departmental committee of 1916 
recommended, since the contributions seemed inadequate in certain 
respects, that a part of these deductions should be diverted to the 
two special funds described below. This meant a diversion of sinking 
fund moneys for more or less immediate purposes, and a delay in the 
final cancellation of the reserve values from 1932 to 1938. The de- 


FINANCIAL ADMINISTRATION. 


41 


ductions made for the two special funds left the amount as follows: 
In the case of men, l^d. (2.3 cents, par); in the case of women, 
l|d. (2.4 cents, par). 

With the deductions at these rates, the following table was pre¬ 
pared by the actuaries of the system; these reserve values are no 
longer in force, but, since the tables for the 1920 rates have not yet 
been published, they show the method used. 

RESERVE VALUES IN RESPECT OF EMPLOYED CONTRIBUTORS WHO ENTERED INTO 
INSURANCE AFTER OCTOBER 12, 1913, UNDER THE AGE OF 69. (SUPERSEDED BY 
ACT OF 1920.) 

[Source: Reserve and Transfer Regulations, 1918. Second schedule. £ at par=$4.8665; shilling=24.3 

cents; penny= 2.03 cents.] 


Age next 
birthday at 
entry into 
insurance. 

Reserve values. 

Age next 
birthday at 
entry into 
insurance. 

Reserve values. 

Men. 

Spinsters 

and 

widows. 

Married 

women. 


Men. 

Spinsters 

and 

widows. 

Married 

women. 


£ 5. 

d. 

£ s. d. 

£ s. d. 


£ s. 

d. 

£ *. i 

d. 

£ s. 

d. 

17 




7 10 

6 

44. 

7 19 

6 

7 17 

6 

8 12 

6 

18 

0 10 

0 

0 6 6 

7 4 

6 

45. 

8 5 

6 

8 5 

6 

8 18 

0 

IQ 

0 17 

0 

0 10 6 

6 16 

6 

46. 

8 12 

0 

8 13 

0 

9 4 

0 

90 

1 4 

0 

0 14 0 

6 9 

0 

47. 

8 18 

0 

9 0 

0 

9 10 

0 

21 

1 11 

0 

0 17 0 

6 3 

6 

48. 

9 4 

0 

9 6 

6 

9 15 

6 

22 

1 18 

0 

10 0 

5 19 

6 

49. 

9 9 

6 

9 13 

0 

10 1 

0 

23 

2 4 

6 

13 0 

5 17 

0 

50. 

9 14 

6 

9 18 

6 

10 5 

6 

24 

2 10 

6 

15 6 

5 15 

6 

51. 

9 19 

6 

10 3 

6 

10 9 

6 

25 

2 16 

0 

18 6 

5 14 

6 

52. 

10 3 

6 

10 7 

6 

10 13 

0 

26 

3 1 

6 

1 11 6 

5 14 

6 

53. 

10 6 

6 

10 11 

0 

10 15 


27 

3 7 

0 

1 15 0 

5 15 

0 

54. 

10 9 

0 

10 13 

0 

10 17 

0 

2 « 

3 12 

0 

1 19 6 

5 16 

0 

55. 

10 10 

6 

10 14 

6 

10 17 

6 

7Q 

3 17 

0 

2 4 6 

5 17 

6 

56. 

10 10 

6 

10 14 

0 

10 16 

6 


4 2 

0 

2 10 0 

5 19 

6 

57. 

10 .8 

6 

10 12 

0 

10 14 

0 

31 

4 7 

0 

2 16 6 

6 1 

6 

58. 

10 5 

0 

10 7 

6 

10 9 

0 

3? 

4 12 

0 

3 3 0 

6 3 

6 

59. 

9 19 

0 

10 1 

0 

10 2 

6 

33 . ; . 

4 17 

0 

3 10 

6 6 

0 

60. 

9 10 

6 

9 12 

0 

9 13 

0 

34 

5 2 

0 

3 17 6 

6 9 

0 

61. 

8 19 

0 

9 0 

0 

9 1 

0 


5 7 

0 

4 5 6 

6 12 

0 

62. 

8 5 

6 

8 6 

0 

8 6 

6 

36 

5 12 

0 

4 13 6 

6 15 

6 

63. 

7 10 

0 

7 9 

6 

7 10 

0 

37 

5 17 

6 

5 16 

6 19 

0 

64. 

6 12 

0 

6 11 

6 

6 12 

0 

ga 

6 3 

6 

5 9 6 

7 3 

0 

65. 

5 12 

0 

5 12 

0 

5 12 

0 

39 

6 9 

0 

5 17 6 

7 7 

0 

66 . 

4 10 

0 

4 10 

6 

4 10 

6 

40 

6 15 

0 

6 6-0 

7 11 

6 

67. 

3 6 

6 

3 8 

0 

3 8 

0 

41 

7 1 

0 

6 14 0 

7 16 

0 

68 . 

2 3 

6 

2 6 

6 

2 6 

6 

4? 

7 7 

0 

7 2 0 

8 1 

0 

69. 

1 12 

0 

1 16 

0 

1 16 

0 

43. 

7 13 

0 

7 10 0 

8 6 

6 









THE CONTINGENCIES FUND. 

The departmental committee of 1916 reported that the existing 
financial provisions of the insurance acts were not sufficiently elastic 
to meet the strain of temporary periods of excessive sickness. They 
recommended the creation of a contingencies fund for each society, 
as a measure of reinsurance within the society itself, for the purpose 
of enabling the society to meet casual variations in the claim rate, 
or alternatively to be available for return in the form of additional 
benefits to the members as a result of favorable conditions, and 
thus to give the members an interest in securing a high level of ad¬ 
ministration. This feature of having each society receive the ad¬ 
vantage of efficient management and, conversely, bear the cost of 
lax management is always emphasized by the official studies on the 














































































42 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


system. A society which has accumulated a surplus by careful 
management must not be deprived of the larger benefits which it 
can then afford to give its members by being called on to subsidize 
another society which has a deficiency because of less careful man¬ 
agement. For this reason the resources of the contingencies fund 
are. to be devoted entirely to the society which has provided them—- 
in fact the moneys might just as well be left in the safe box of each 
society. As far as the use of this fund is concerned, though, as 
will be stated in connection with the central fund, one-eighth of the 
amount diverted from the original sinking fund income is actually 
placed in a “pool” for the benefit of all societies. 

The management of the moneys for the contingencies fund is in 
the hands of the three insurance authorities, the Ministry of Health 
for England and Wales, the Scottish Board of Health, and the Irish 
Insurance Commissioners. The fund is fed by the following sums: 
Under the act of 1918 the amounts were seven-eighths “of a sum 
representing in the case of men four-ninths, and in the case of women 
three-ninths, of a penny for each weekly contribution paid in respect 
of a member of a society.” Under the act of 1920 these amounts 
were increased so that they now are seven-eighths of two-thirds of a 
penny in the case of men and of one-half penny in the case of women. 
This increase was necessary to provide for the larger benefits of the 
1920 act. To these amounts should be added the interest accumu¬ 
lations. 

The deductions placed in the fund are those which would have 
been credited if the fund had been in existence since the commence¬ 
ment of the system. 

The apportionment of the contingencies fund among the societies 
is regulated by section 3 of the 1918 act. The men’s contributions 
are placed in one account and this is apportioned among the socie¬ 
ties in proportion to the number of men’s contributions each society 
has made, together wfith the share of interest earned. The same 
procedure is followed in the case of the women’s contributions. 
The amount so apportioned is from time to time to be made avail¬ 
able for making good any deficiency which may appear when a quin¬ 
quennial valuation is made; if there is no deficiency, or if there is a 
balance after covering the deficiency, the amount mus.t be placed 
in the benefit fund of the society. The society, however, may not 
use such a receipt to provide any of the “ additional benefits ” de¬ 
scribed on page 32. 

CENTRAL FUND. 

The central fund is a common fund for all societies, to be drawn 
upon to meet deficiencies shown to exist at a five-year valuation; 
it is administered by the National Health Insurance Joint Com¬ 
mittee. The fund is fed, first by the remaining one-eighth of the 
amount deducted from the contingencies and central funds, that is, 
one-eighth of the following: Two-thirds of a penny for men and one- 
half penny for women. Under the 1918 act, the rates were one- 
eighth of the following: Men four-ninths penny, women three- 
ninths penny. The second source of income of the central fund is 
an annual appropriation by Parliament of £150,000 ($729,975, par) 
beginning with the year 1917. To these sums is added the interest 


FINANCIAL ADMINISTRATION. 


43 


earned. Although the fund was created by the act of 1918, the 
deductions credited to it are the sums which would have been placed 
there had the plan been in force from the beginning of the system. 

The distribution of the central fund is regulated by section 4 of 
the 1918 act, which provides that if on the valuation of a society a 
deficiency is found to exist and the sums available in the contin¬ 
gencies fund are not sufficient to make good the deficiency then 
the central fund may be drawn upon under the following condi¬ 
tions: The National Health Insurance Joint Committee may direct 
that the whole or a part of the deficiency shall be covered out of the 
central fund if the committee is satisfied that the deficiency is due 
in whole or in part to an abnormal rate of sickness among the mem¬ 
bers on account of “the nature of their employment or environment, 
or their physical condition or any epidemic disease, or is due to the 
rate of sickness being abnormal by reason of the small membership 
of the society or branch, or is due to any other special cause beyond 
the control of the society or branch.” 

If at any time the joint committee decides that after taking into 
account the necessity of creating a proper reserve, the sums stand¬ 
ing to the credit of the central fund are more than sufficient for the 
purposes of the fund, the committee may by regulations provide for 
decreasing the amounts stated above and make a corresponding 
increase in the amounts to be placed in the contingencies fund. 

THE WOMEN’S EQUALIZATION FUND. 

The departmental committee of 1916 found that while the ex¬ 
penditure for sickness and maternity benefits in respect of men’s 
insurance was substantially within the provision made for it, the 
same expenditure for women’s insurance was distinctly in excess of 
the provision of the insurance acts. The original estimates of the 
system were based on the Manchester Unity of Odd Fellows’ experience 
for men, but heavily weighted to allow for greater sickness among 
women. The 1916 committee found that, in the light of the fuller 
Imowledge available after several years’ operation, the pressure of 
sickness claims of women had been underestimated and that there 
was a lack of balance between net provision and benefit. It was 
also found that, apart from the general excess in the expenditure 
upon claims for sickness benefit for women, experience had shown 
that married women in particular appeared to be subject to a greater 
amount of sickness than women generally and that this further ex¬ 
cess emerged in the experience of the societies in proportion to the 
number of married women included in their membership. 

To correct this inadequate provision, the committee made two 
recommendations. The first was that the amounts set aside for the 
redemption of reserve values had been found to be slightly greater 
than was necessary in the case of women, and they proposed that the 
rate should be changed from l^d. (3 cents, par) (1911 law) to ljd. 
(2.5 cents, par). This would immediately release a larger sum 
for benefits for women generally, while correcting an excessive charge 
for sinking fund purposes. This was part of the deductions already 
referred to under the contingencies funds’ amounts. ? 

The second recommendation was the establishment of a women s 
equalization fund. As finally worked out in the 1918 law, this fund 


44 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


was to be devoted to meeting the sickness claims of women of approved 
societies. The annual income of the fund is a sum not exceeding 10s. 
($2.43, par) per married woman employed contributor, and the plan 
of distribution is prepared by the joint committee with the approval 
of the treasury. The money is appropriated by Parliament for this 
purpose, and the 10s. is increased by the usual grant of two-ninths of a 
weekly contribution notwithstanding the fact that the income was 
wholly or partly provided by Parliament. 

Under the 1911 act, it was for a while a matter of doubt whether 
disability due to pregnancy formed a valid claim for sickness benefit, 
as the practice of friendly societies had varied in this respect. Be¬ 
cause of this lack of uniformity of treatment of woman members, 
Parliament acceded to the request of the societies and made an 
appropriation “for grants toward the cost of sickness benefit, includ¬ 
ing loss of contributions incurred since the commencement of the 
act, by approved societies having woman members, on a basis calcu¬ 
lated with reference to the relative incidence of incapacity during 
pregnancy among such members, £500,000 [$2,433,250, par].” This 
sum was granted in the budget for 1915-16; for 1916-17, the amount 
was £100 ($486.65, par); and for 1917-18 it was £10,000 ($48,665, par). 
Because of war conditions these amounts were not distributed, and 
when the 1918 act provided for the women’s equalization fund, the 
£510,100 ($2,482,402, par) were placed in it to be distributed to 
the societies on the basis of 8s. ($1.95, par) per married woman who 
was a member of a society and an employed contributor. The 1920 
act increased the rate from 8s. to 10s. ($1.95 to $2.43, par). At the 
time the 1918 act was passed it was understood that the Government 
would regularly appropriate £250,000 ($1,216,625, par) for the fund; 
in the estimates the amount needed for 1920 would have been £280,000 
($1,362,620, par), but the act of 1920 increased this sum to £350,000 
($1,703,275, par). It seems, therefore, that Parliament has com¬ 
mitted itself to providing this amount regularly in the future, and the 
undertaking was largely made because of its great importance as an 
aid in reducing the infantile mortality rate aside from its value in 
protecting the health of the mothers. 

THE VALUE OF THE BENEFITS. 

The question as to what the insured person gets in return for his 
contribution has been computed by the actuaries in connection with 
the revision of the system introduced by the act of 1920. The 
insured man pays 5d. (10.1 cents, par) and the insured woman pays 
4d. (8.1 cents, par) per week; to these amounts the employer adds 5d., 
making the total paid lOd. and 9d. (20.3 cents and 18.3 cents, par), 
respectively. Besides these payments, the State adds two-ninths of 
the cost of benefits (including expenses of administration of the socie¬ 
ties and of the insurance committees) as well as certain special grants. 
The basis on which the rates have been calculated is that for an en¬ 
trant of the age of 16, using the tables given on pages 47 and 48, 
prescribed by the valuation regulations of 1919. The portion of the 
contributions appropriate to each item of benefit is as follows, seven- 
ninths of the contribution being allotted: 


FINANCIAL ADMINISTRATION. 


45 


Weekly Contribution for Seven-Ninths Benefit. 
[Penny at par=2.03 cents.] 

Men. 

d. 

Sickness benefit. 3. 02 

Disablement benefit. 1.11 

Maternity benefit.68 

Medical benefit.1.92 

Expenses of administration.94 


Total. 


7.67 


Women. 

d. 

2. 68 
.92 
.49 
2.01 
.98 

7. 08 


Men. 

Women. 

d. 

d. 

■ n 


§ 

h 


1A 

. 10 

9 


The amounts set aside for cancellation of reserve values and for 
the contingencies and central funds are described on page 40; the 
apportionment of the full contribution—lOd. (20.3 cents, par) for 
men and 9d. (18.3 cents, par) for women—is as follows: 

[Penny at par=2.03 cents.] 

To benefit fund (including administration)... 7§ 

To contingencies fund and central fund. f 

To redemption of reserve values. l| 

Total. 

As only about one-seventh of the insured women remain in em¬ 
ployment after marriage, there is a marked difference in the amounts 
necessary to be allotted to the two sexes. This comes out promi¬ 
nently in the case of the disablement benefit. The largest part of the 
contributions must be devoted to providing the sickness benefit, 
with medical benefit coming next in amount. The maternity benefit 
of 40s. ($9.73, par) calls for 0.68d. and 0.49d.(1.38 cents and 0.99 
cent, par) of the contribution of men and of women, respectively. 
These amounts are about 9 per cent and 7 per cent, respectively, of 
the contributions. 

The benefits described above, the redemption of the reserve values, 
and the two funds which are in effect reinsurance funds, therefore 
require the entire amount of the full contribution—namely, the lOd. 
and 9d. The normal benefits in the case of a person entering at 
age 16 are thus of jequal value with the contributions; the State 
grant of two-ninths, in actual practice, counterbalances the charge 
on new entrants for both the contingencies fund and the redemption 
of reserved values, so that he receives the full amount of his contribu¬ 
tion. This is increased by the fact that the contingencies funds 
belong entirely to his society, either to prevent a decrease of benefit 
in case of deficiency or to provide extra benefits in case of surplus. 
Another factor of increase is the State grant for the women’s equaliza¬ 
tion, which will after 1920 be about £450,000 ($2,189,925, par). 
Considering all these items, the actuaries who made the estimates for 
the 1920 act state that the full value of the benefits is equivalent, in 
the case of a man, to 10.6d. (21.5 cents, par) per week as against 
a contribution of lOd. (20.3 cents, par), half of which is paid by the 
employer; while in the case of women-the value of the benefits is 
10.Id. (20.5 cents, par) per week as against a contribution of 9d. (18.3 
cents, par), 5d. of which is paid by the employer. Stated very briefly 

104936°—23—Bull. 312-4 












46 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


and without endeavoring to be minutely accurate, the insured man 
pays 5d. and receives 10.6d weekly; the insured woman pays 4d. and 
receives 10.Id. weekly. 

RESERVE SUSPENSE FUND. 

If a member of an approved society ceases to be an insured person, 
then his transfer value is placed in a special fund called the reserve 
suspense fund. This fund must be kept in two accounts, one for 
men and one for women. Whenever a person enters the insurance, 
his (or her) reserve value is provided out of the sums standing in 
the reserve suspense fund. This fund must be invested in the same 
manner as the assets of the National Health Insurance Fund. 

THE ACTUARIAL VALUATION. 

T^ e act 1911 provided that a valuation of the assets and lia¬ 
bilities. of the carriers should be made every three years; this short 
period was originally adopted in order that changes in benefits or 
the assessment of a levy might be made quickly in case a deficiency 
should occur in the operations of the approved societies under the 
act. The committee of 1916 found that this brief period was for 
all practical purposes an unnecessary burden on the societies and 
recommended a five-year period. This was adopted by Parliament 
and the act of 1918 required that a valuation should be made every 
five years at least, and oftener if the commissioners so decide. The 
first valuation was taken as of December 31, 1918, and a preliminarv 
report of the results was issued in March, 1921, under the title “In¬ 
terim report of the Government actuary upon the valuation of 
the assets and liabilities of approved societies as at 31st December 
!9i8, ” being Command Paper No. 1130 of 1921. The main features 
of this report are given below. 

The plan used in making the valuation is set forth in Statutory 
Rules and Orders No. 1119 of 1919, entitled “National insurance 
valuation regulations, 1919, ” printed in September, 1919. These 
regulations give specific instructions to be followed in computing 
the value of benefits, contributions, investments, etc.; they are the 
usual rules followed by actuaries in such valuations and are given 
m detail in order to secure absolute uniformity in all cases Of 
special importance, however, are the four tables appended to these 
regulations, showing (1) the expectancy of life, (2) the expectancy of 
sickness and disablement, (3) the “issue rate” to indicate liability 
lor maternity benefit, and (4) the expectancy of marriage. These 
lour tables are as follows: 


FINANCIAL ADMINISTRATION. 47 


LIFE TABLE: PROBABILITY THAT A PERSON OF AN EXACT AGE AS SHOWN IN THE 
FIRST COLUMN WILL SURVIVE ONE YEAR. 

[Source: National Insurance Valuation Regulations, 1919. Statutory Rules and Orders, 1919, No. 1119. 

London, 1919. Page 9.] 


Age. 

Men. 

Women. 

16. 

0.99699 

0.99738 

17. 

.99689 

.99730 

18. 

.99678 

.99722 

19. 

.99666 

.99713 

20. 

.99654 

.99703 

21. 

.99642 

.99693 

22. 

.99629 

.99682 

23. 

.99615 

.99670 

24. 

.99600 

.99657 

25. 

.99585 

.99644 

ft 

26. 

.99568 

.99630 

27. 

.99550 

.99615 

28. 

.99531 

.99598 

29. 

.99510 

.99581 

30. 

.99489 

.99563 

31. 

.99466 

.99544 

32. 

.99441 

.-99523 

33. 

.99414 

.99501 

34. 

.99386 

.99478 

35. 

.99356 

.99454 

36. 

.99323 

.99428 

37. 

.99287 

.99401 

38. 

.99249 

.99372 

39. 

.99208 

.99342 

40. 

.99163 

.99310 

41. 

.99115 

.99277 

42. 

.99063 

.99241 

43. 

.99007 

.99203 

44. 

. 98946 

.99162 

45. 

.98880 

.99118 

46. 

.98809 

.99071 

47. 

.98732 

.99019 

48. 

.98648 

.98963 

49. 

.98556 

.98901 

50. 

.98457 

.98833 

51. 

.98349 

.98757 

52. 

.98231 

.98673 

53. 

.98103 

.98579 

54. 

.97964 

.98474 

55. 

. 97813 

.98357 

56. 

.97649 

.98227 

57. 

.97470 

.98083 

58. 

.97276 

.97923 

59. 

.97064 

.97745 

60. 

.96834 

.97549 

61. 

.96584 

.97334 

- 


Age. 

Men. 

Women. 

62. 

0.96313 

0.97099 

63. 

.96018 

.96841 

64... 

.95699 

.96560 

65. 

.95352 

.96254 

66. 

.94976 

.95922 

67. 

.94569 

.95560 

68. 

.94129 

.95167 

69. 

.93653 

.94742 

70. 

.93138 

.94282 

71. 

.92582 

.93783 

72. 

.91982 

.93243 

73. 

' .91335 

.92660 

74. 

.90637 

.92030 

75. 

.89886 

.£1349 

76. 

.89078 

.90614 

77. 

.88210 

.89822 

78. 

.87276 

.88968 

79. 

.86273 

.88047 

80. 

.85197 

.87054 

81. 

.84043 

.85983 

82. 

.82806 

.84829 

83. 

.81480 

.83585 

84. 

.80060 

.82245 

85. 

.78541 

.80800 

86. 

.76916 

.79241 

87. 

.75178 

.77559 

88. 

.73320 

.75744 

89. 

.71336 

.73786 

90. 

.69219 

.71672 

91. 

.66961 

.69388 

92. 

.64554 

.66920 

93. 

.61989 

.64253 

94. 

.59258 

.61371 

951. 

.56353 

.58257 

96. 

.53266 

.54894 

97. 

.49989 

.51263 

98. 

.46515 

.47345 

99. 

.42887 

.43122 

100. 

.38950 

.38579 

101. 

.34850 

.33703 

102. 

.30534 

.28491 

103. 

.26000 

.22960 

104. 

.21246 

.17164 

105. 

.16270 

.11222 

106. 

.11071 

.05363 










































































































48 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN 


AVERAGE NUMBER OF WEEKS’ SICKNESS AND DISABLEMENT BENEFITS PAYABLE 

PER MEMBER WITHIN ONE YEAR. 

[Source: National Insurance Valuation Regulations, 1919. Statutory Rules and Orders, 1919, No. 1119. 

London, 1919. Page 10.] 


Age. 

Men. 

Women. 

Sick- 

ness. 

Dis¬ 

able¬ 

ment. 

Sick¬ 

ness. 

• 

Dis¬ 

able¬ 

ment. 

16. 

0.938 


1.154 


17. 

.920 


1.137 


18. 

.888 

0.038 

1.104 

0.051 

19. 

.349 

.054 

1.063 

.071 

20. 

.814 

.071 

1.025 

.094 

21. 

.788 

.089 

.995 

.119 

22. 

.773 

.108 

.976 

.144 

23. 

.769 

.127 

.968 

.170 

24. 

.769 

.143 

.965 

.190 

25. 

.773 

.158 

.967 

.209 

26. 

.776 

.170 

.968 

.225 

27. 

.779 

.182 

.971 

.238 

28. 

.787 

.190 

.977 

.250 

29. 

.797 

.201 

.985 

.263 

30. 

.808 

.214 

.995 

.279 

31. 

.822 

.230 

1.006 

.299 

32. 

.837 

.249 

1.018 

.323 

33. 

.851 

.271 

1.031 

.348 

34. 

.867 

.293 

1.045 

.374 

35. 

.885 

.319 

1.061 

.404 

36. 

.905 

.348 

1.079 

.438 

37. 

.928 

.382 

1.099 

.478 

38. 

.955 

.420 

1.122 

.523 

39. 

.983 

.463 

1.147 

.572 

40. 

1.012 

.507 

1.174 

.621 

41. 

1.043 

.551 

1.202 

.671 

42. 

1.073 

.595 

1.230 

.720 


Age. 

Men. 

Women. 

Sick¬ 

ness. 

Dis¬ 

able¬ 

ment. 

Sick¬ 

ness. 

Dis¬ 

able¬ 

ment. 

43. 

1.104 

0.640 

1.258 

0.772 

44. 

1.134 

.687 

1.286 

.823 

45. 

1.166 

.740 

1.316 

.882 

46. 

1.202 

.799 

1.349 

.948 

.47. 

1.244 

.870 

1.388 

1.027 

48. 

1.290 

.955 

1.431 

1.120 

49. 

1.340 

1.055 

1.478 

1.229 

50. 

1.395 

1.172 

1.528 

1.359 

51. 

1.449 

1.311 

1.579 

1.509 

52. 

1.507 

1.465 

1.633 

1.676 

53. 

1.568 

1.639 

1.691 

1.865 

54. 

1.639 

1.828 

1.756 

2.070 

55. 

1.716 

2.035 

1.829 

2.292 

56. 

1.798 

2. 264 

1.907 

2.538 

57. 

1.887 

2.518 

1.992 

2.890 

58. 

1.979 

2.806 

2.080 

3.117 

59. 

2.074 

3.147 

2.171 

3.480 

60. 

2.179 

3.553 

2.270 

3.913 

61. 

2. 292 

4.044 

2.378 

4.436 

62. 

2.409 

4.633 

2.490 

5.061 

63. 

2.529 

5.316 

2.604 

5.786 

64. 

2.650 

6.087 

2.719 

6.603 

65. 

2. 769 

6.946 

2.835 

7.509 

66. 

2.894 

7.899 

2.953 

8.518 

67. 

3.020 

8.971 

3.074 

9.651 

68. 

3.142 

10.183 

3.191 

10.932 

69. 

3.247 

11.543 

3.292 

12.368 


Note.—T he £bove are “central rates,” i. e., the ratios of the total number of weeks of sickness or 
disablement benefit payable during the year of age following the exact age given in the table to the 
number of persons alive in the middle of tnat year of age. 


The above figures for England give an average of about If weeks 
of sickness per insured person per annum; this would be raised to 
about 2 weeks of disability per annum if account were taken of 
(a) the 4 days of waiting time before sickness benefit becomes pay¬ 
able; (b) accidents; and (c) other sicknesses on account of which 
benefit is not paid. Under English conditions, therefore, the insur¬ 
ance system must make financial provision for each insured person 
being incapacitated for from If to 2 weeks each year. 


















































































financial administration 


49 


MATERNITY BENEFIT: PROBABILITY OF ISSUE TO A MEMBER DURING ONE YEAR. 


[Source: National Insurance Valuation Regulations, 1919, Statutory Rules and Orders 1919, No. 1119. 

London, 1919, p. 11.] 


Age. 


16. 

17. 

18. 

19. 

20. 

21 . 

22 . 

23. 

24. 

25. 

26. 

27. 

28. 
29, 

30 

31 

32 

33 

34 
35. 

36 

37 

38 

39 

40 

41 

42 


Men. 

Married 

women. 1 

Spinsters 

and 

widows. 1 

Age. 

Men. 

Married 

women. 


0. 4000 

0.0019 

43. 

0.0734 

0.0499 


.6000 

.0062 

44.... 

.0635 

.0343 

0.0015 

.6900 

.0087 

45. 

.0544 

.0215 

.0089 

.6700 

.0099 

46. 

.0464 

.0119 

.0271 

.6030 

.0105 

47. 

.0394 

.0056 

.0533 

.5336 

.0107 

48. 

.0333 

• .0021 

.0803 

.4759 

.0106 

49. 

.0279 

.0006 

.1046 

.4291 

.0102 

50. 

.0233 

.0001 

. 1260 

.3909 

.0095 

51. 

.0193 


. 1440 

.3592 

.0084 

52 

.0159 


.1588 

.3327 

.0072 

53. 

.0130 


. 1704 

.3105 

.0057 

54 

.0107 


. 1791 

.2916 

.0042 

55 

.0086 


. 1848 

.2753 

.0028 

56 

.0069 


1877 

.2608 

.0015 

57 

.0055 


.1882 

.2474 

.0007 

58 . 

.0045 


. 1860 

.2344 

.0002 

59 . 

.0036 


. 1815 

. 2213 

.0000 

60 

.0029 


. 1747 

.2080 

61. 

.0024 


. 1661 

. 1940 


62. 

.0019 


. 1558 

. 1788 


63. 

.0015 


. 1444 

1622 


64 . 

.0011 


1323 

. 1444 


65 . 

.0008 


. 1200 

. 1256 


66 . 

.0006 


1076 

. 1062 


67. 

.0004 


0956 

.0866 


68 . 

.0002 


.0841 

.0676 


69. 

.0001 



i Provision for posthumous births is made in the rates applicable to married women and not in the rates 
applicable to wiaows. 

Note.—T he above are “central rates,” i. e., the ratios of the number of maternity benefits payable in 
the year o f age following the exact age given in the table to the number of persons alive in the middle of that 
year of age. 

PROBABILITY OF MARRIAGE (WOMEN) AND OF BECOMING A WIDOW. 

[Source: National Insurance Valuation Regulations, 1919, Statutory Rules and Orders, 1919, No. 1119. 

London, 1919, p. 12.] 


Age. 

Probability 
of marriage. 
(Spinsters 
and widows.) 

Probability 
of becoming 
a widow. 

Age. 

Probability 
of marriage. 
(Spinsters 
and widows.) 
*- 

Probability 
of becoming 
a widow. 

16 

0.0071 

0.0041 

43. 

0.0135 

0.0129 

17 

.0164 

.0041 

44. 

.0121 

.0138 

Ik 

.0309 

.0042 

45. 

.0109 

.01*7 

19 

.0494 

.0043 

46. 

.0098 

.0156 

20 

.0689 

.0044 

47. 

.0088 

.0166 

91 

.0866 

.0045 

48. 

.0079 

.0177 

22 

.1005 

.0046 

49. 

.0071 

.0190 

09 

.1085 

.0047 

50. 

.0063 

.0205 

94 

.1112 

.0048 

51. 

.0056 

.0221 


.1091 

.0050 

52. 

.0049 

.0238 

96 

.1035 

.0052 

53. 

.0043 

.0255 

97 

.0955 

.0054 

54. 

.0037 

.0272 

9k 

.0862 

.0056 

55. 

.0033 

.0290 

9Q 

.0766 

.0058 

56. 

.0028 

.0309 

QA 

.0672 

.0061 

57. 

.0024 

.0329 


.0586 

.0064 

58. 

.0021 

.0351 

99 

.0509 

.0067 

59. 

.0018 

.0376 

99 

.0443 

.0070 

60. 

.0016 

.0406 


.0386 

.0073 

61. 

.0014 

.0441 

OX 

.0338 

.0077 

62. 

.0012 

.0479 

on 

.0298 

.0081 

63. 

.0010 

.0517 

97 

.0264 

.0086 

64. 

.0009 

.0555 

9k 

.0234 

.0091 

65. 

.0008 

.0594 

9Q 

.0208 

.0097 

66. 

.0007 

.0632 


.0186 

.0104 

67. 

.0006 

.0673 

41 

.0167 

.0112 

68. 

• .0005 

.0715 

42. 

.0150 

.0120 

69. 

.0004 

.0762 


Note.—T he above are “central rates,” e. g. the probability of marriage of a spinster or a widow is the 
ratio of the number of marriages in a year of age following the exact age given in the table to thenumber 
of spinsters and widows alive in the middle of that year of age. 











































































































































































50 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


The preliminary report on the valuation above referred to covers 
about 40 per cent of the valuations and includes 5,036 societies and 
branches, with 2,752,308 members. The general results of the valua¬ 
tions may be summarized as follows: 

In the case of 4,878 societies and branches, comprising 2,704,371 members, the 
valuations have disclosed surpluses, the aggregate amount of the surpluses being 
£3,609,248 [$17,564,405, par]. Deficiencies have been found on the valuations of 
155 societies and branches having a membership of 47,539. The total amount of the 
deficiencies is £15,974 [$77,737, par]. In three cases, with a total membership of 
398, the assets and liabilities balance exactly. 

The following table shows the results of these valuations: 


PARTIAL REPORT OF RESULTS OF THE VALUATIONS OF APPROVED SOCIETIES 

DECEMBER 31, 1918. ’ 


[Source: Interim report by the Government actuary upon the valuation of the assets and liabilities of 
approved societies as at 31st Dec., 1918. London, 1921. Cmd. 1130, p. 4. £ at par=$4.8665.] 


Country. 


Valuations showing 
surpluses. 


Valuations showing 
deficiencies. 


Valuations 
showing an 
exact balance 
of assets and 
liabilities. 



Number 
of socie¬ 
ties and 
branches. 

Num¬ 
ber of 
mem¬ 
bers. 

Total 
amount of 
surpluses. 

Number 
of socie¬ 
ties and 
branches. 

Num¬ 
ber of 
mem¬ 
bers. 

Total 
amount 
of defi¬ 
ciencies. 

Number 
of socie¬ 
ties and 
branches. 

Num¬ 
ber of 
mem¬ 
bers. 

England. 

4,224 

333 

104 

217 

2,027,321 
270,768 
185,605 
220,677 

£2,816,479 
490,279 
174,319 
128,171 

117 

4 

6 

28 

33,836 
802 
8,580 
4,321 

£10,517 

369 

3,257 

1,831 

3 

398 

Scotland. 

Ireland. 



Wales. 



United Kingdom. 

4,878 

2,704,371 

3,609,248 

155 

47,539 

15,974 

3 

398 


This table gives the results of the valuations for the entire member¬ 
ship. As the benefits vary for men and for women, the composition 
of the membership is of importance. As many societies admit both 
men and women and insure them in a common fund, it was not 
possible to separate the data completely for the sexes. From the 
available information, the following table was compiled* 


PARTIAL REPORT OF THE RESULTS OF THE VALUATIONS OF APPROVED SOCIFTTFQ 
BY CLASS OF MEMBERSHIP, DECEMBER 31, 1918 SOCIETIES, 

[Source: Interim report by the Government actuary upon the valuation of the assets and liabilities of 
approved societies as at 31st Dec., 1918. London, 1921. Cmd. 1130, p. 4. £ at par=$4.866AJ 


Class. 

Valuations showing surpluses. 

Valuations showing deficiencies. 

Number of societies and 
branches. 

Number 
of mem¬ 
bers. 

Total 
amount of 
surpluses. 

Number of societies and 
branches. 

Num¬ 
ber of 
mem¬ 
bers. 

Total 
amount 
of defi¬ 
ciencies. 

Eng¬ 

land. 


Scot¬ 

land. 

Ire¬ 

land. 

Wales. 

Eng¬ 

land. 

Scot¬ 

land. 

Ire¬ 

land. 

Wales. 

Men only 1 . 

Women only.... 
Men and women 
in common in¬ 
surance. 

2,519 

297 

1,408 

85 

26 

222 

34 

4 

66 

99 

1 

117 

1,029,362 

170,562 

1,504,447 

£1,604,516 
169,056 

1,835,676 

66 

17 

34 

1 

2 

12 

16,999 

4,397 

26,143 

£6,087 

1,466 

8,421 

3 

4 

16 

Total. j. 

4,224 

333 

104 

217 

2,704,371 

3,609,248 

117 

4 

6 

28 

47,539 

15,974 



i In England there are also three cases with 398 members in which the assets and liabilities balance exactly. 


















































































FINANCIAL ADMINISTRATION. 


51 


The most conspicuous result of the valuations is that the amount 
of the surpluses is quite large, while the amount of the deficits is 
relatively insignificant. The Government actuary states that con¬ 
ditions which have prevailed during the war “have greatly affected 
the finance of national health insurance, and it is evident that to a 
material extent the surpluses now declared are due to this cause.” 
He sums up the principal factors which have entered into the produc¬ 
tion of the surpluses as follows: 

(а) The claims for sickness, disablement, and maternity benefits have been con¬ 
siderably below the provision made for the expenditure under these heads in the 
financial basis of the acts. 

As regards the sickness and maternity benefits much of the resulting gain is trace¬ 
able to the fall in the claims which set in with the year 1915 and continued until 1918. 
No previous experience of friendly societies affords a parallel to this phenomenon, 
which is unmistakably connected with the war. 

It is important to remember in this connection that the supernormal experience of 
men who were invalided from the forces has been met by an annual grant from the 
exchequer. The relatively heavy liability of married women, which at one time 
attracted attention, has also been corrected by an annual grant from public funds. In 
respect, therefore, of both men and women, the societies have been protected from 
elements of liability that were outside the scope of the original estimates, and accord¬ 
ingly reap the full advantage of the favorable experience which has prevailed. 

In the case of disablement benefit the claims have steadily risen, as they must do 
for some years to come, since disablement benefit represents the provision for more or 
less permanent incapacity among a community all of whose members were in employ¬ 
ment on first entering into insurance, in or after the year 1912. The increase in the 
cost of disablement benefit has, however, been considerably less than that anticipated, 
though it should be added that this feature is much less noticeable in the case of women 
than it is in the case of men. 

(б) The interest realized on the investments of the accumulated funds has been 
appreciably in excess of the valuation rate of 3 per cent. Interest at this rate is 
credited in respect of reserve values, which at present form the major part of the assets 
of approved societies, but the great bulk of the funds accumulated since 1912 has been 
invested in Government securities producing, especially since the war, a much higher 
rate. Approved societies are exempt from income tax on interest, and therefore 
obtain the full benefit of the high rates of interest at which they have been enabled to 
invest. 

The element of depreciation had not up to the valuation date become a serious factor, 
and the valuation regulations provided that stock exchange securities held by societies 
should be taken at their cost prices. So far as the funds of societies consist, under 
statutory directions, of credits in the commissioners’ investment account (comprising 
approximately 50 per cent of the total amount accumulated) the question of depre¬ 
ciation may be presumed, in any case, not to arise, since by appropriate regulations, 
prescribing the rate of interest allowed, provision may be made for the creation of 
sufficient reserves to protect the fund. The rate of interest at present allowed in re¬ 
spect of these credits is 4 per cent, leaving, it is understood, a suitable margin for the 
purpose here indicated. 

(c) The receipts from contributions in many cases have exceeded the ‘* expectation. ’* 
Contributions are not payable in periods of sickness or unemployment, and it follows 
that in years when sickness is below the average and employment abundant the re¬ 
ceipts from contributions show a considerable gain to societies. These conditions 
prevailed generally up to 31st December, 1918. 

(d) ‘ ‘ War mortality, ’ ’ in the case of men, has added greatly to surplus. The liabili¬ 
ties of societies have been reduced by deaths of which there had been no expectation, 
while the credits given, and the funds accumulated, to meet those liabilities remain 
intact. 

While much of the favorable sickness and disablement experience of 
the societies has been due to war conditions, the actuary also ascribes 
part of it to the favorable environment and the nature of the occu¬ 
pations of many of the insured persons. Thus the membership of 
rural societies and of societies including such occupations as bank 
clerks, journalists, teachers, etc., have shown favorable results. 


52 NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 

Another feature which has aided in producing the surplus, or at 
any rate which affects the result, is the quality of administration of 
the societies. In some of the cases of deficiencies and of small sur¬ 
plus, the quality of administration has been clearly the cause of the 
unfavorable results. 

Disposition of the surplus .—Under the insurance acts a society is 
authorized to submit a plan for the distribution of the surplus in 
the form of additional benefits, provided that the actuary certifies 
the surplus to be disposable. It is recommended that appropriate 
plans for this purpose be approved, but that such additional Dene- 
fits shall be restricted to five-year periods—that is, to the period of 
the quinquennial valuation. 

In certifying a surplus as disposable, the per capita reserve for the 
legal benefits is taken as 11s. ($2.68, par) for men and 9s. ($2.19, par) 
for women. In only a few cases has the surplus been shown to be 
smaller than this reserve and of course in such instances the surplus 
is not disposable. In the great majority of cases the balance avail¬ 
able for distribution is considerable, the total amount certified as 
disposable being £2,171,576 ($10,567,975, par), or on the average 62 
per cent of the related surpluses. 

The disposable surpluses are classified by country and by type of 
society in the table following, reproduced from the interim report of 
the Government actuary. 

DISPOSABLE SURPLUSES, BY SEX OF MEMBERSHIP AND BY COUNTRY. 

[Source: Interim report by - Go e.nn mt actuary upon the valuation of the assets and liablilities of 
approved societies as "Is . lCU. London, 1921. Cmd 1130. Page 7. £ at par=$4.8665. 


Sex of men. k -sh.-), and ec ntry. 

Number of 
societies 
and 

branches. 

Number of 
members. 

Amount of 
disposable 
surplus. 

3 vs:. 

Men only. 

2,391 

270 

1,649 

942,289 
147 575 

£977 116 

Women oi /. 

103,’764 

i non aga 

Men and v\ :men * jo.emo.: in¬ 
surance. 

1 242 310 



i, uyu,oyo 

Total. 

4,310 

2,332,174 

9 171 *V7A 


Z, I / 1, o# o 

COD' T_ Y 

England. 

3,753 

314 

85 

158 

1,860,584 

1,700,788 
322,233 
106,571 
41,984 

Scotland. 

Ireland. 

-wvj/ , \Ji o 

137 932 

Wales. 



OO,Ooo 

United Kingdom. 

4,310 

2 332 174 

2,171,576 




According to the preceding table the valuations included in the 
interim report show that 85 per cent of the insured persons in the 
societies covered by the report are in a position to receive additional 
benefits. 

Amount of additional benefits .—Some of the additional benefits 
permissible under the law are not capable of being measured by 
actuarial computation, but in the case of the normal pecuniary bene¬ 
fits such estimates can be made with a reasonable degree of accuracy. 
Such a calculation has been made on the assumption that all of the 



























GENERAL ADMINISTRATION. 53 

available surplus is used for additions to the existing pecuniary 
benefits on the following basis: 

Is. (24.3 cents, par) a week additional sickness benefit. 

6d. (12.2 cents, par) a week additional disablement benefit. 

2s. (48.7 cents, par) additional maternity benefit. 

On this basis the following table shows the number of persons in 
whose cases the disposable surplus admits, if applied wholly to this 
purpose, of the payment of each rate of additional sickness benefit 
from Is. (24.3 cents, par) to 5s. ($1.22, par), with corresponding addi¬ 
tional disablement and maternity benefits according to the proportion 
given in the preceding paragraph. 

NUMBER OF INSURED PERSONS WHO CAN BE GRANTED ADDITIONAL BENEFITS 
OF VARYING AMOUNT, ON THE RESULTS OF VALUATIONS OF APPROVED SOCIE¬ 
TIES, DECEMBER 31, 1918. 

[Source: Interim report by the Government actuary upon the valuation of the assets and liabilities of 
approved societies as at 31st Dec., 1918. London, 1921. Cmd. 1130. Page 8. Shilling at par=24.3 
cents; penny=2.03 cents ] 


Additional benefits. 

England. 

Scotland. 

Ireland. 

Wales. 

United Kingdom. 

Sick¬ 

ness 

w ( K. 

Dis¬ 

able¬ 

ment 

(per 

week). 

Ma¬ 

ter¬ 

nity. 

Men. 

Wom¬ 

en. 

Men. 

Wom¬ 

en. 

Men. 

Wom¬ 

en. 

Men. 

Wom¬ 

en. 

Men. 

Wom¬ 

en. 

s. d. 
1 0 

•s. d. 
0 6 

8 . 

2 

114,328 

46,257 

8,050 

4,788 

21,656 

6,913 

12,311 

1,712 

156,345 

59,670 

1 6 

0 9 

3 

110,295 

44,315 

10,450 

1,133 

2,507 

278 

17,996 

6,088 

141,248 

51,814 

2 0 

1 0 

4 

324,966 

46,410 

16,037 

11,509 

2,710 

1,182 

5,278 

1,055 

348,991 

60,156 

2 6 

1 3 

5 

161,338 

49,763 

8,999 

4,992 

17,600 

10,589 

7,261 

971 

195,198 

66,315 

3 0 

1 6 

6 

166,380 

30,890 

11,297 

6,012 

5,798 

2,508 

4,360 

2,255 

187,835 

41,665 

3 6 

1 9 

7 

154,337 

31,583 

13,563 

7,669 

21,502 

18,027 

1,042 

186 

190,444 

57,465 

4 0 

2 0 

8 

159,631 

24,689 

17,688 

20,435 

2,516 

864 

780 

28 

180,615 

46,016 

4 6 

2 3 

9 

103,382 

16,022 

17,788 

4,478 

660 

356 

585 

24 

122,415 

20,880 

5 0 

2 6 

10 

170,341 

22,552 

90,943 

4,256 

6,278 

4,550 

2,304 

197 

269,866 

31,555 

Total-- 


1,464,998 

312,481 

194,815 

65,272 

81,227 

45,267 

51,917 

12,516 

1,792,957 

435,536 


Note.— In the case of certain societies and branches with a total membership of 103,681 (55,566 men 
and 48,115 women) the disposable surplus is insufficient to provide for additional money benefits under 
the above general plan and must be applied to other forms of additional benefit. 


The point of special interest in the table is the large number of 

E ersons who come in the line in which the highest rate—5s. sickness 
enefit, etc.—is given. 

Deficiencies.—In the case of the societies having a deficiency, the 
actuary reports that it seems probable that the contingencies funds 
will be sufficient to make good all the claims that may be made upon 
them. 

GENERAL ADMINISTRATION. 

The insurance system is managed by three bodies, the Ministry of 
Health in England and Wales, the Scottish Board of Health, and the 
Irish Insurance Commissioners. Parliament fixes the limits of their 
powers, but for all practical purposes it may be said that the three 
systems of administration are independent, though acting under the 

same laws. . . _ , , . 

In the present account of the administration the system used for 
England and Wales will be followed, as the Scottish and Irish systems 
follow the same general plan, but with numerous variations to adjust 





























54 NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 

it to the needs of those countries. The total number of insured per¬ 
sons in the United Kingdom in 1920 was about 15,850,000, of whom 
about 13,380,000 were residents of England and Wales, so that about 
85 per cent of the insured persons are subject to the Ministry of 
Health. 

Under the ministry the principal part of the work of the insurance 
system is carried on by two sets of organizations; the medical benefit 
and the sanatorium benefit (in part) are administered by the insurance 
committees, there being one such body for each administrative area; 
the other benefits, the pecuniary, are provided through voluntary or¬ 
ganizations called “ approved societies,” whose membership, the in¬ 
sured persons, is scattered throughout the country. 

Aiding the ministry is an independent, federated body called the 
National Health Insurance Joint Committee, composed of representa¬ 
tives from the four countries, whose chief function is to aecide on 
matters common to all the countries and more particularly the 
actuarial problems. 

Under the ministry are two advisory bodies entitled “ consultative 
councils,” whose function is to give advice and assistance to the 
minister. 

Mention should also be made of a special organization called the 
deposit contributors’ fund, intended to provide benefits for such per¬ 
sons as do not join the “ approved societies.” 

MINISTRY OF HEALTH. 

The 1911 act provided that the insurance system should be ad¬ 
ministered by four boards, entitled “ insurance commissioners,” there 
being one for each of the four countries of the United Kingdom. 
These bodies continued in control of the system until July 1, 1919, 
when the new Ministry of Health took charge of affairs in England 
and Wales. The act 4 creating the new ministry was approved on 
June 3, 1919, the ministry came into being on June 25, and the powers 
and duties of the insurance commissioners (England) and the Welsh 
insurance commissioners were transferred to it on July 1, 1919. A 
number of other national authorities were placed under the jurisdic¬ 
tion of the minister, the most important being the local government 
board; but for present purposes, the authority over health insurance 
matters only need be considered. 

The establishment of the ministry was the result of an agitation 
of several years for a centralization of the health activities of the 
National Government. The war brought clearly before the country 
the need for greater activity in preserving and improving the standard 
of health of the people; as in the United States, the military service 
acts showed in Great Britain a very high proportion of men below 
the standard of physique ordinarily required for military service; 
the infant mortality rate had been characterized by Mr. Lloyd George 
as “disgraceful;” the shortage of housing was so acute as to become 
a menace to public health, and other problems equally pressing were 
calling for action. In most of these matters earnest efforts had been 
made to ameliorate the evils connected with them, usually by 
creating a separate organization to handle the problem. In 1919 it 






GENERAL ADMINISTRATION. 


55 


was not difficult to prove that the large number of authorities work¬ 
ing on matters such as the above were wasting much effort and 
money by the lack of a central controlling authority to prevent over¬ 
lapping and to require cooperation in work. It is not easy to state 
how much influence the facts brought out by the operation of the 
insurance system had in focusing attention on health problems, but 
one of the members of the committee which investigated the insurance 
system could say with entire propriety as early as 1914 that— 

The national insurance act has done great service in bringing to light a mass of suf¬ 
fering and a number of social evils, as to which the nation as a whole was ill-informed 
or indifferent. It will now be substantially easier than in 1911, both on account of 
the new knowledge available and of the state of public opinion, to make adequate 
provision to advance the health of the community. 

A later report of the Ministry of Reconstruction made a similar 
statement. 

The original act of 1911 placed the control of the system in England 
in the hands of a body entitled “the insurance commissioners”; this 
board was appointed by the treasury, and in 1911 consisted of nine 
members, one of whom was a woman. In general they represented 
the friendly societies, the trade-unions, the medical profession, etc. 
Their work was summarized as follows-' 

1. To deal with the approved societies. 

2. To deal with the collection of contributions and the receipt and issue of funds, 
and to make the necessary accounting arrangements. 

3. To deal with the insurance committees. 

4. To deal with the provisions of the act as affecting individual insured persons 
and classes of insured persons. 

5. To control and organize the work of the outdoor staff (the field force) of the 
commission. 

The Ministry of Health took over the employees and property of 
the commissioners and have in general continued the work on the 
lines as established by their predecessors. The duties of the ministry 
are so numerous that they can be stated as being that of the super¬ 
vision and administration of the system for England and Wales. 

NATIONAL HEALTH INSURANCE JOINT COMMITTEE. 

Since July 1, 1919, this committee has been composed of the Min¬ 
ister of Health as chairman, the Secretary for Scotland, the Chief Sec¬ 
retary for Ireland, and one other person appointed by the Minister 
of Health, having special knowledge and experience of national health 
insurance in Wales. 

This committee makes financial adjustments between the health 
insurance funds of the different countries, has charge of the actuarial 
valuation of the approved societies, has charge of the approval of so¬ 
cieties operating in more than one country, etc. The most important 
part of their work is that relating to actuarial questions. 

CONSULTATIVE COUNCILS. 

Section 4 of the Ministry of Health act authorized the appointment 
of consultative councils in England and Wales for the purpose of 
giving advice and assistance to the minister in connection with such 
matters affecting or incidental to the health of the people as may be 
referred to in the order in council establishing them. Every such 


56 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


council must include women as well as men and must consist of per¬ 
sons having practical experience of the matters referred to it. 

Four such councils are authorized, one of which is entitled ‘‘con¬ 
sultative council on national health insurance” (approved societies 7 
work). It consists of 20 members. 

The council is required to discuss and report on matters referred 
to it by the minister, or it may on its own motion report to the min¬ 
ister on any subject within its field. 

In the discussions in Parliament on the act of 1920 the minister 
made a special acknowledgment of the value of the services rendered 
by the council in the preparation of the bill. 

INSURANCE COMMITTEES. 

Medical, and, in part, sanatorium benefits are administered by the 
insurance committee, there being one such committee for each 
county or county borough. Cooperating with this committee are 
the local medical committee, the panel committee, and the pharma¬ 
ceutical committee; these three committees provide a means for se¬ 
curing proper expression of the opinion of the medical profession and 
of the pharmaceutical profession in matters relating to the insurance. 

The insurance committee must consist of not less than 40 or more 
than 80 members, consisting of the following persons: (1) Three- 
fifths of the membership must be representatives of the insured per¬ 
sons; (2) one-fifth must be appointed by the council of the county; 
(3) two members shall be elected by the association representing 
the medical profession in the area; (4) one to three members, who 
are duly qualified medical practitioners, shall be appointed by the 
council of the county; (5) other members appointed by the minister. 

A number of the members must be women. 

The constitution and by-laws of the insurance committee, the regu¬ 
lations as to their employees, and their proceedings generally are to 
be prescribed by the minister or must be approved by him. 

In certain cases the area covered by an insurance committee must 
be subdivided, and a “district insurance committee” must be created. 
These have similar powers and duties. In the same manner insur¬ 
ance committees may be consolidated at the discretion of the minister. 

Besides the administration of the medical benefit, the powers and 
duties of the insurance committees are: 

1. They must make reports on the health of the insured persons 
in the area subject to their jurisdiction; the minister may transmit to 
the councils of the county (county borough), etc., copies of reports 
made by the committee. 

2. They must make provision for the giving of lectures and the 
publication of information on questions relating to health as they 
deem desirable. 

3. They must keep records and accounts in the form prescribed 
by the minister. 

The legal position of an insurance committee is that of a body 
corporate. It has perpetual succession, a common seal, may sue and 
be sued, and, subject to the approval of the ministry, may take, 
purchase, and hold land for purposes within the terms of the insur¬ 
ance laws. 


GENERAL ADMINISTRATION. 


57 


The local medical committee is a voluntary organization of medical 
practitioners for the purpose of representing their interests under the 
system. If the minister is satisfied that such a committee is properly 
representative of the profession, he may give it official recognition 
and require the insurance committee to consult it on all general 
questions affecting the administration of the medical benefit, in¬ 
cluding such matters as giving attendance and treatment to insured 
persons. 

The panel committee is composed of physicians who have agreed 
to serve as panel doctors. Where the insurance committee is re¬ 
quired by law or regulation to ascertain the opinion of the panel 
doctors as to matters of the medical benefit, it must do so by con¬ 
sulting with the panel committee, which shall also perform such 
duties as may be prescribed by the minister. If no local medical 
committee has been given official recognition in any area, then the 
panel committee may be recognized in its stead. 

The pharmaceutical committee is a body in each county (or county 
borough) required to be elected by the persons, firms, corporations, 
etc., who have agreed to supply drugs, medicines, and appliances to 
insured persons. It must, subject to certain regulations, be con¬ 
sulted by the insurance committee in regard to the supply of drugs, 
medicines, and appliances. It may also perform such other duties as 
the minister may prescribe. 

These committees must have travel and subsistence expenses 
paid while attending meetings. For this purpose the insurance com¬ 
mittee may allot an annual sum of not more than Id. (2 cents, par) 
per insured person in the area represented. 

Income of committees .—The act of 1911 (sec. 15, par. 6) provided 
that there should be paid each year to the insurance committee for 
each county, etc., out of the moneys credited to a society which has 
members in that area, such sum in respect of the medical benefit of 
such members and its cost of administration as might be agreed 
upon between the societies and the committee. In default of an agree¬ 
ment decision was to be made by the commissioners. Under the 
act of 1920 this was changed, so that beginning with January 1, 
1920, there is to be paid each year to insurance committees in Great 
Britain, out of the funds for the payment of benefits on account of 
medical benefit, a sum of 9s. 6d. ($2.31, par), and on account of the 
administrative expenses of the insurance committees such sum not 
exceeding 4d. (8.1 cents, par), as may be prescribed in respect of 
each of the total number (calculated in the prescribed manner) of the 
persons who are entitled to medical benefit as being or having been 
members of an approved society. 

The distribution of the money derived on this basis is provided 
for by the medical benefit regulations of 1920. The amounts to be 
paid the doctors are divided into two parts—the central practitioners' 
fund and the mileage fund. The distribution is arranged by a 
distribution committee, consisting of practitioners and others, 
appointed by the minister, and their plans must be approved or may 
be revised by him. On the basis of the distribution of the insured 
population, these sums are allotted to the various insurance com¬ 
mittees, though in some cases no mileage grant is given. Special 
arrangements are made for payments to institutions (hospitals, 
dispensaries, etc.) which provide medical benefit to insured persons. 


58 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


According to the medical regulations, the payments to the panel 
doctors for their services may be made on any of the following plans: 

1. A capitation system or plan of payment on the basis of the 
number of insured persons on the doctor’s list. 

2. An attendance system or plan of payment on the basis of service 
(or visits) actually rendered. 

3. A combined system, in which capitation payments are made, 
together with payment for special classes of service actually rendered. 

4. Any modification of the preceding plans which the minister 
may approve. 

Part of the money collected for medical benefit is used for the 
payment of expenses in providing drugs, medicines, appliances, etc. 
Each insurance committee must report to the minister, at definite 
times and in regular form, the amounts payable by them to persons 
supplying drugs, etc. The minister then credits to the committee 
the sums necessary, which they must keep in an account called the 
drug fund and meet the bills due from it. 

APPROVED SOCIETIES. 

At the time of the enactment of the law of 1911, Great Britain was 
covered by a network of friendly societies, trade-unions, sick clubs, 
establishment funds, and similar voluntary organizations which pro¬ 
vided a variety of benefits for sickness, accidental injmy, death, 
unemployment, and the like. Many of these societies had a long 
history of usefulness in providing relief from distress from these 
causes and had developed a spirit of friendly aid to fellow members— 
the “friendly society spirit”—which made them valuable and efficient 
agencies for the protection of the standard of life in the communities 
in which they operated. Their special activities were insurance or 
relief in cases of sickness, death, and unemployment, and their mem¬ 
bers had had long experience in the handling of such insurance. The 
suggestion of broadening the activities of these organizations into a 
national plan of insurance had been discussed for many years and in 
1908 crystallized into a promise by the Liberal Party that such a plan 
would be offered to Parliament. When the plan was drafted, it was 
decided to use these societies as carriers of the insurance, but in the 
process to interfere with their activities as little as possible. In fact, 
the competition between these societies for members and their rivalry 
in offering benefits and securing good administration were referred to 
as desirable qualifications for the work to be undertaken. The fact . 
that many of them had political, denominational, and social purposes 
was well understood from the start, and they were offered participa¬ 
tion in the insurance with this fact in view. The only fundamental 
requirement exacted was that they should not be operated for profit 
and that they should be democratically managed. 

The first step undertaken was to secure the cooperation of a suffi¬ 
ciently large number of societies to bring the insurance within the 
reach of the population to be insured. Part of this work was readily 
accomplished because of the existing machinery of the societies for 
reaching their members through meetings, periodicals, etc. To act 
as a carrier of the insurance, these societies had to be designated as 
“approved societies” by the higher authorities, namely, the Ministry 


GENERAL ADMINISTRATION. 59 

of Health for England and Wales, and the corresponding bodies for 
Scotland and Ireland. 

This approval is given to— 

1. Any society, that is, any body of persons, corporate or unincor¬ 
porate (not being a branch of another such body), registered or estab¬ 
lished under any act of Parliament or by royal charter. 

2. Any society not so registered or established which has a consti¬ 
tution such as is prescribed by the ministry. 

3. Any separate section established by any society for the purposes 
of the insurance acts, consisting of insured persons and so constituted 
as to comply with the requirements relating to approved societies. 

4. Any new society. 

5. Any establishment fund (“ employers’ provident funds ”), subject 
to certain conditions. 

The approval may be withdrawn for failure to comply with the laws, 
for offenses against any laws, or for maladministration of the society’s 
affairs. 

The first important part of securing approval is the submission of 
the constitution, laws, and regulations of the society. Copies of these 
documents must be submitted to the ministry, where they are 
examined to ascertain whether they comply with the insurance laws 
and regulations. 

A frequent procedure is for a society to add a Part Two to its 
organization; this is popularly called the “State side,” as distin¬ 
guished from the “ private side” for the conduct of the society’s regu¬ 
lar business. By this arrangement the society merely adds a new 
department to its organization; this additional department does not 
cause any change in the existing arrangements as to meetings, gov¬ 
ernment, etc. An important feature of the approval of a society is 
the submission of their book of rules; these must receive special 
approval and no changes may be made without the consent of the 
ministry. For registered friendly societies, the approval of the chief 
registrar of friendly societies is also necessary. 

The plan of organization of t&e societies is the one usually provided 
for such purposes; there must be a presiding officer, trustees, secre¬ 
tary, treasurer and committee of management. As the general 
executive officer, the secretary is the official with whom the insured 
persons come into frequent contact and he is the one who communi¬ 
cates with the insurance authorities. The treasurer is the custodian 
of the uninvested funds of the societies and makes all payments, for 
which authority must be given. The trustees have the duty of hold¬ 
ing and being responsible for all deeds, documents of title, and invest¬ 
ment securities. They are the authorities to sue and be sued on behalf 
of the society. The committee of management (board of directors, 
executive committee, etc.), is appointed by the members for the gen¬ 
eral policy and direction of the society’s business and for the supervi¬ 
sion of its operations. There must also be arrangements for a general 
meeting of members or for a series of district meetings in order that the 
requisite democratic control of the society may be assured. Careful 
records of the transaction of business relating to the state insurance 
must be kept on file and open to the inspectors and auditors of the 
ministry. 

Membership .—Membership in a society, as far as the “State side” 
is concerned, is a matter of contract; the applicant, by sending in a 


60 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


proposal for membership, offers to pay his contributions through the 
society and to conform to its rules. The society, by accepting this 
offer, undertakes to pay him his benefits. The various classes of 
members (contributors) are described on page 12. The termination 
of this contract occurs when the member ceases to be insured. 

Types of societies.—An account of the various voluntary societies 
providing sickness insurance is given imthe twenty-fourth annual 
report of the United States Commissioner of Labor (Vol. II, p. 1550 
ff.) This description also gives a historical account of some of the 
more important societies and statistics of their operations down to 
1909. By far the greater part of these organizations have elected to 
become approved societies and are at present providing State insur¬ 
ance. The latest available information as to the distribution of 
the insured persons among these societies in England is contained in 
the following table: 


APPROXIMATE DISTRIBUTION OF MFMBERS OF APPROVED SOCIETIES AMONG THE 
VARIOUS GROUPS OF SOCIETIES FOR THE HALF YEAR ENDED JUNE, 1919. 

[Source: Second annual report of the Ministry of Health, 1920-21. London, 1921. • Cmd. 1446. Page 153.] 


Type of society and sex of members 

Friendly 

societies 

(branches). 

Friendly 

societies 

(central¬ 

ized). 

Industrial 
and col¬ 
lecting 
societies. 

Trade- 

unions. 

Employ¬ 
ers’prov¬ 
ident 
funds. 

Totals for 
all groups 
of societies. 

Societies approved by joint com¬ 
mittee: 

Men. 

2,006,000 

631,750 

1,339,000 

665,200 

2,848,000 

2,601,900 

789,200 

89,900 

41,500 

5,700 

7,023,700 

3,994,450 

Women. 

Total. 

2,637,750 

2,004,200 

5,449,900 

879,100 

47,200 

11,018,150 

Societies approved for operation in 
England only: 

Men. 

52,550 

15,800 

768,250 
194,450 

4,850 

3,900 

213,600 
114,150 

45,450 
* 18,850 

1,084,700 
347,150 

Women. 

Total. 

68,350 

962,700 

8,750 

327,750 

64,300 

1,431,850 

Total membership of approved so¬ 
cieties in England: 

Men. 

2,058,550 

6^7,550 

2,107,250 
859, R0 

2,852,850 
2,605, ©00 

1,002,800 

204,050 

86,950 

24,550 

8,108,400 

4,341,600 

Women. 

Total ... 

2,706,100 

2,966,900 5,458,650 

1,206,850 

111,500 

12,450,000 



Of the more than 12,000,000 insured persons in England, nearly 
one-half are members of the two classes of friendly societies, while 
over two-fifths are in the societies conducted by the industrial in¬ 
surance companies and in the societies called “ collecting societies.” 
The trade-unions rank third in the number of persons included. In 
the case of insured women it will be noted that over one-half of them 
are included in the combined group of commercial insurance com¬ 
panies’ societies and collecting societies. 

The almost infinite variety of organizations used as carriers is 
illustrated by the names of the societies which sent witnesses to tes¬ 
tify before the departmental committee of 1916; a few of these names, 
picked out at random, are: 

Presbyterian Health Insurance Society. 

General Federation of Trade Unions. 

United Ancient Order of Druids Friendly Society. 

National Union of Railwaymen’s Approved Society. 

British Steel Smelters’ Mill, Iron and Tinplate Workers’ Approved Society, 
































GENERAL ADMINISTRATION. 


61 


Independent Order of Odd Fellows, Manchester Unity Friendly Society. 

Dublin Catholic Young Men’s Insurance Society. 

Amalgamated Union of Cooperative Employees. 

Scottish Women’s Friendly Society. 

Hearts of Oak Benefit Society. 

National Union of Women Workers of Great Britain and Ireland. 

National Federation of Women Workers. 

“Achei Brith” (Brethren of the Covenant) Friendly Society. 

Teachers’ Provident Society. 

Prudential Approved Societies. 

Order of Sons of Temperance Friendly Society. 

St. Finbarr’s Diocesan Health Insurance Society. 

Dublin Protestant Insurance Society. 

Scottish Rural Workers’ Friendly Society. 

Association of Approved Society Secretaries. 

Bradford Municipal Officers’ Health Insurance Society. 

Durham Miners’ Association Approved Society. 

Orange and Protestant Friendly Society. 

Scottish Clerks’ Association. 

Transfers between societies .—When an insured person desires to give 
up his membership in one society and to join another, he is entitled 
to make this transfer, subject to certain restrictions. These restric¬ 
tions are placed solely for the purpose of reducing the administrative 
work, which is rather heavy, involved in making the changes in the 
records of the society. A member may not, for instance, make the 
change except at prescribed times, usually at the end of a contribu¬ 
tion period and at intervals not greater than 27 weeks. To protect 
a society which has a deficiency or which for other reasons objects 
to such a transfer, the commissioners may, on receipt of objection 
from the society and after giving the member opportunity to state 
his reasons, decline to authorize such transfer. A society may also, 
subject to the consent of the commissioners (i. e., the ministry), for¬ 
bid any transfers for a period of not more than one year after a val¬ 
uation which has shown a deficiency. If a person has been a mem¬ 
ber of a society for less than two years, a fee may be charged for the 
transfer. The restrictions are designed to prevent frivolous changes, 
but at the same time there is no desire to hinder members from join¬ 
ing organizations which provide greater advantages because of better 
management. When a person transfers his membership, he takes 
with him the accumulated rights of reserve values; these are called 
“ transfer values” and are given in a series of tables published in the 
1918 compilation of laws and regulations on pages 282 to 295. Two 
comparatively recent regulations have been issued, containing the 
rules for modifying these tables to make them conform to the 1920 
act. The tables are too extensive to reproduce here. 

ASSOCIATIONS OF SOCIETIES. 

The law as planned did not exclude a society whose membership 
was too small to afford an adequate basis for the insurance from 
joining the system. They were, however, required to make some 
sort of pooling arrangements with other small societies as a measure 
of reinsurance. The 1911 act placed 5,000 members as the smallest 
number with which a society might operate independently, but the 
act of 1918 reduced this number to 1,000. 

104936°—23—Bull. 312-5 


62 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


The smaller societies are required to join a central association, 
under the rules prescribed by the Ministry of Health; the association 
must have a central financial committee to direct its operations in 
regard to making good deficiencies shown after a valuation/> 'In other 
respects, these associations are to be treated as if they were societies 
with branches. 

In addition to these ‘‘pooling” associations, many approved so¬ 
cieties have formed voluntary organizations or committees to pro¬ 
vide. for themselves accountants, auditors, nursing arrangements, 
visiting of beneficiaries, the services of medical referees, etc. 


THE DEPOSIT CONTRIBUTORS’ FUND. 


Under the system of insurance carried on by the voluntary organi¬ 
zations grouped under the term “approved societies,” it was not 
feasible to compel them to accept persons for membership against 
their wishes, though the law prohibits any society from refusing ad¬ 
mittance solely on the ground of age. Many of the approved soci¬ 
eties for instance are trade-unions whose members must be engaged 
in a specified craft, while other societies restrict their membership 
on the basis of religious belief, etc. The framers of the law expected 
that there would on this account be a large number of persons who 
could not secure membership on this ground. It was also expected 
that there would be a large number who could not secure admit¬ 
tance because of impaired health; in fact it was expected that such 
poor “risks” would form the major part of these unaffiliated persons 
subject to the law. For all such persons, a special organization was 
created, now called the deposit contributors’ fund, originally the post- 
office fund. The first estimate of the framers of the law was that 
such persons would number about 800,000 or 900,000. Later events 
showed that nearly all of these estimates were incorrect. As a rule, 
these societies have waived any right to a medical test of applicants 
for membership and the result is that the members of the deposit 
contributors’ fund differ in no important respect from the great body 
of insured persons and their number has always been much smaller 
than the original estimates of the framers of the law. The fund was 
at first expected to be a temporary expedient only; the act of 1911 
required that it be discontinued on January 1, 1915, but for a variety 
of reasons the fund has been continued from year to year since that 
date. In the debate in the House of Commons, the Minister of 
Health m replying to the criticism that provision had not been made 
to improve the condition of the deposit contributors, said (Commons 
Debates, March 22, 1920, p. 218): 


The deposit contributors are not such unfortunate persons as the honorable mem- 
SjL f® ems to };hink. They are in some respects the aristocracy of the insurance con¬ 
tributors. they are, in the mam, deposit contributors by their own choice. Many 
balances W0U ^ to ^ ave them. Some of them have accumulated considerable 


At another time the minister said (March 24, 1920): 

There is no evidence of any general desire for the abolition of deposit contributors 
i * at there 18 an appreciable number of insured persons un- 

? admission to approved societies, I will refer to the insurance con- 
sultatn e council the question of making some alternative arrangements. 


OPERATIONS OF THE SYSTEM. 


63 


EXCESSIVE SICKNESS. 

One of the broad powers of the insurance system is its authority 
in regard to investigation of excessive sickness. Where the minister, 
or an approved society, or an insurance committee, alleges that the 
sickness for which benefits must be paid is excessive, and that such 
excess is due to the conditions or nature of the employment of such 
persons, or to the bad housing or insanitary conditions in any locality, 
or to an insufficient or contaminated water supply, or to the neglect 
of the authorities (or any person) to observe or enforce any law 
relating to the health of workers in industrial establishments, then 
the insurance authorities may apply for an investigation, or the 
minister may conduct one, for the purpose of determining whether 
a claim is valid for the repayment of such excessive costs to the 
insurance system. If, after proper inquiry, it is found that the ex¬ 
cess of sickness exceeds the average by more than 10 per cent, then 
the following reimbursements may be demanded: 

1. If due to the neglect of an employer, it must be made good by 
him. 

2. If due to bad housing, or local insanitary conditions, or neglect 
of a local authority to observe or enforce health laws, then the loss 
must be made good by the local authority or by the person responsible 
for the insanitary housing. 

3. If due to insufficient or contaminated water supply, then the 
loss must be made good by the local authority or water company 
or person by whom the water is supplied. 

The minister may recover such a sum by deducting it from the 
local taxation account or by any other method of recovery. 

OPERATIONS OF THE SYSTEM. 

SOURCES OF INFORMATION. 

The administrative authorities of the system have published 
five reports on the operations of the system; the first was for the 
year 1912-13, the second for 1913-14, the third for 1914-1917, 
and the fourth, the first annual report of the Ministry of Health, 
Part IV (Cmd. 913 of 1920), covers the period 1917 to March 31, 
1920, while the second annual report (Cmd. 1446) covers 1920-21. 
Aside from these five administrative reports, the available informa¬ 
tion as to the 'working of the system is in such form that it is difficult 
to summarize. The statistical information, so important in show¬ 
ing the operations of an insurance system, is distinctly limited. 
The almost entire independence of the four countries of tne United 
Kingdom is shown by the fact that the reports contain no consolidated 
statement for the latter. However, one summary statement of 
especial value was published in connection with the work of an inves¬ 
tigating committee. The absence of statements in the present 
study as to the number of cases of sickness, duration and nature of 
sickness, etc., is due to the fact that the data have not yet been 
published. There is some information as to the working of the 
sanatorium benefit, given on page 69, though this does not include 
the duration of treatment given. 


64 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


Two reports of special value are that of the investigating com¬ 
mittee of 1916 and that of the Government actuary on the status 
of the system in connection with the revision of benefits in 1920. 

One of the most useful sources of information is the question 
department of the House of Commons Debates; the information 
presented depends on the nature of the question asked the Govern¬ 
ment by the .member who submits it, but it frequently happens that 
the data so given contain facts which have not yet been published. 

With the coming into force of the Ministry of Health Act of 1919, 
the chief medical officer of that ministry began to publish an annual 
report, which gave a systematic survey of health conditions in 
England and Wales subject to the jurisdiction of the ministry. One 
feature of this survey is the medical aspect of the insurance acts. 
To date three of these reports have been issued, beginning with 
that for 1919-20 (Cmd. 978). In these reports is the beginning of 
a series of statistical summaries on the operations of the acts, though 
as yet the data are distinctly limited in scope. 

Under the terms of the central index committee regulations 
(England) of August 29, 1922, a special body was created for the 
purpose of keeping registers, records, etc., as the basis of statistical 
and other reports on the insured and exempt persons affected by the 
system. No reports have as yet been issued. A similar committee 
for Wales was also created. 

The accounts of the national health insurance funds are published 
from time to time in separate papers presented to Parliament. 
The latest available, published in 1920, brings the information 
down to 1916. 

The sanatorium benefit return is also made in a separate paper 
and brings the information in rather brief form. 

The budget statement of the Government is the best guide to 
what is being done in the financial part of the system; the health 
insurance part of the budget comes m Class VII. 

As a means of showing the actual workings of the system, the 
reports of the. various. approved societies have a distinct value; 
sometimes the information given is so fragmentary as to have little 
value as a contribution to the development of the system, but to 
a foreign reader, the point of view and the matters of particular 
interest emphasized are of real importance. For a few societies, 
selected at random as instances of this material, the latest available 
annual report has been given in condensed form. 

NUMBER OF PERSONS INSURED. 

The first full year of operation of the system was 1913; according 
to the summary statement of the table on page 65, in this year 
there were 9,394,961 men and 4,053,108 women, or a total of 
13,448,069 persons in the insurance in 1913. During the years of 
the war, it was deemed inadvisable to report on the number of per¬ 
sons insured, but in connection with the bill of 1920, the Govern¬ 
ment actuary made an estimate of the number of insured persons, 
which is as follows: 


OPERATIONS OF THE SYSTEM. 


65 


ESTIMATED NUMBER OF INSURED PERSONS, 1920. 

[Source: Ministry of Health. National health insurance bill, 1920. Report by the Government actuary 
upon the financial provisions of the bill. London, 1920. Cmd. 612. Page 5.] 


Locality. 

Men. 

Women. 

Approved 

societies. 

Deposit 

contributors. 

Approved 

societies. 

Deposit 

contributors. 

England. 

i 8,300,000 
1,130,000 
490,000 
630,000 

250,000 

30,000 

10,000 

10,000 

3,920,000 

530,000 

260,000 

140,000 

125,000 
15,000 
5,000 
5,000 

Scotland. 

Ireland. 

Wales. 

United Kingdom. 

10,550,000 

300,000 

4,850,000 

150,000 


1 Including persons entitled to benefits out of the navy and army insurance fund. 


According to this estimate, the number of persons within the scope 
of the insurance in July, 1920, was about 15,850,000, of whom 
10,850,000 were men and 5,000,000, or 32 per cent, were women. The 
number in England was 12,595,000, or not quite 80 per cent. Of the 
total number of men insured, 8,550,000, or not quite 80 per cent, were 
in England. Of the total number of women insured, 4,045,000, or 
slightly over 80 per cent, were in England. The round figures used 
indicate with emphasis the fact that these statements are estimates. 

As stated above, the number of persons insured in societies in 
1913 was 13,448,069; compared with the number for 1920, namely 
15,400,000 (omitting the deposit contributors), there was an increase 
of about 14 per cent in seven years. It is perhaps not accurate to 
compare the details of the 1920 estimate with the actual returns of 
1913, but with this reservation, the number of women in approved 
societies increased from 4,053,108 to an estimated number of 4,850- 
000 in 1920, an increase of about 20 per cent. The corresponding 
increase for men was about 12 per cent. It is probable that the 
changes resulting from war conditions are responsible for the more 
rapid increase in the number of women insured. 


EXPENDITURE FOR PECUNIARY BENEFITS. 

The expenditures of the approved societies for sickness, mater¬ 
nity, and disablement benefits in the years 1913-1916 were as follows: 

EXPENDITURE OF APPROVED SOCIETIES FOR SICKNESS, MATERNITY, AND DIS- 
ABLEMENT BENEFITS, BY YEARS, 1913 TO 1916. 

[Source- Interim report of the departmental committee on approved society finance and administration. 
London 1916 Cd. 8251. Page 37. Report on the administration of national health insurance during 
the years 1914-1917. London, 1917. Cd. 8890. Pages 116 and 238. £ at par =84.8665; penny=2-03 
cents.] 


Country. 


1913—Men: 

England. 

Scotland. 

Ireland. 

Wales. 

United Kingdom. 


Number 

of 

members. 


7,359,866 
1,026,649 
457,227 
551,219 


9,394,961 


Sickness 

benefit. 


£ 

3,413,052 
422,564 
230,119 
322, 377 


4,388,112 


Mater¬ 

nity 

benefit. 


£ 

938,837 
137,332 
68,339 
78,139 


Disable¬ 

ment 

benefit. 


1,222,647 


All pecu¬ 
niary 
benefits. 


£ 

4,351,889 
559, 896 
298,458 
400,516 


5,610, 759 


Average expenditure 
per week. 


Sick¬ 

ness 

bene¬ 

fit. 


d. 

2.14 
1.90 
2.32 
2. 70 


2.16 


Ma¬ 

ter¬ 

nity 

bene¬ 

fit. 


d. 

0.59 
.62 
.69 
.65 


.60 


Dis¬ 

able¬ 

ment 

bene¬ 

fit. 


All 

bene¬ 

fits. 


d. 

2.73 
2.52 
3.01 
3.35 


2.76 

































































66 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN 


EXPENDITURE OF APPROVED SOCIETIES FOR SICKNESS, MATERNITY, AND DIS¬ 
ABLEMENT BENEFITS, BY YEARS, 1913 TO 1916—Concludod. 


Country. 

Number 

of 

members. 

Sickness 

benefit. 

Mater¬ 

nity 

benefit. 

Disable¬ 

ment 

benefit. 

All pecu¬ 
niary 
benefits. 

Av 

Sick¬ 

ness 

bene¬ 

fit. 

erage 

per 

Ma¬ 

ter¬ 

nity 

bene¬ 

fit. 

xpend 

week. 

Dis¬ 

able¬ 

ment 

bene¬ 

fit. 

iture 

All 

bene¬ 

fits. 

1913—Women: 


£ 

£ 

£ 

£ 

d. 

d. 

d. 

d. 

England. 

3,290,807 

1,756,610 

31,995 


1,788,605 

2.46 

.04 


2.50 

Scotland. 

'43L404 

' 199,' 068 

7; 031 


1 206,099 

2.13 

.08 


2.21 

Ireland__ 

221,432 

148' 145 

2,304 


iso; 449 

3.08 

.05 


3.13 

Walet. 

109,465 

62,752 

1 ,579 


64,331 

2.63 

.07 


2.70 









United Kingdom. 

4,053,108 

2,166,575 

42,909 

1 

2,209,484 

2.46 

.05 


2.51 

1914—Men: 










England. 

7,537,794 

3,944,065 

956,917 

115,958 

5,016,940 

2.41 

.58 

0.07 

3.06 

Scotland. 

1,033,276 

507,233 

144,309 

17,443 

668,985 

2.26 

.64 

.08 

2.98 

Ireland. 

474,544 

253,809 

73,139 

3,367 

330,315 

2. 46 

.71 

.03 

3.20 

Wales. 

579,948 

378,629 

84,974 

9,650 

473,253 

3.38 

.76 

.09 

4.23 

United Kingdom. 

9,625,562 

5,083,736 

1,259,339 

146,418 

6,4S9,493 

2.43 

.60 

.07 

3.10 

1914—Women: 










England. 

3,336,285 

1,728,104 

177,003 

36,222 

1,941,329 

2.39 

.24 

.05 

2.68 

Scotland. 

446,337 

210, 744 

17,788 

6,775 

235,307 

2.17 

.18 

.07 

2.42 

Ireland. 

231,291 

120,341 

13,248 

1,177 

134, 766 

2.39 

.26 

.02 

2.67 

Wales. 

117,912 

67,547 

2,874 

1,588 

72,009 

2.63 

.11 

.06 

2.80 

United Kingdom. 

4,131,825 

2,126,736 

210,913 

45, 762 

2,383,411 

2.37 

.23 

.05 

2.65 

1915—Men: 










England. 

o 

3,631,223 

864,609 

457,384 

4,953,216 

2. 21 

.53 

.28 

3.02 

Scotland. 

0) 

478,073 

130,318 

69,918 

678,309 

2.13 

.58 

.31 

3. 02 

Ireland. 

0) 

220,193 

65, 717 

21,672 

307,582 

2.13 

.64 

.21 

2.98 

Wales. 

0) 

318,280 

75, 751 

40, 948 

434,979 

2.84 

.68 

.37 

3.89 

United Kingdom. 

0 ) 

4,647,769 

1,136,395 

589,922 

6,374,086 

2. 22 

.54 

.28 

3.04 

1915—Women: 










England. 

0 ) 

1,335,994 

154,318 

198,464 

1,688, 776 

1.84 

.21 

.27 

2.32 

Scotland. 

W 

170,755 

14, 719 

34, 706 

220,180 

1.76 

.15 

.36 

2. 27 

Ireland.. 

(4 

95, 765 

10,614 

10,214 

116,593 

1.91 

.21 

.20 

2. 32 

Wales. 

(9 

53,659 

2,852 

8,343 

64,854 

2.09 

.11 

.33 

2.53 

United Kingdom. 

(9 

1,656,173 

182,503 

251,727 

2,090,403 

1.84 

.20 

.28 

2.32 

1916—Men: 






* 




England. 

(9 

3,409,914 

828,854 

587,671 

4,826,439 





Scotland. 

(9 

451,472 

128,365 

9i; 451 

671,288 

2.06 

.58 

.42 

3.06 

Ireland. 

(9 

213, 290 

59, 782 

38,176 

311,248 





Wales. 

(9 

299 513 

72,137 

52; 724 

416, 374 












United Kingdom. 

(9 

4,366,189 

1,089,138 

770,022 

6,225,349 





1916—Women: 










England. 

(9 

1,147,652 

147, 334 

294, 530 

1,589,516 





Scotland. 

(9 

142,783 

12,674 

47; 544 

203,001 

1.48 

. 13 

.49 

2.11 

Ireland. 

(9 

89, 815 

8,356 

21, 893 

120,064 





Wales. 

(9 

46; 292 

2, 766 

12 ; 000 

61,058 












United Kingdom. 

(9 

1,426,542 

171,130 

375,967 

1,973,639 






1 Not reported. 

As the insured persons were required to have been members for 
26 weeks before they became entitled to benefits for sickness and 
maternity, no benefits on this account were payable until January, 
1913, as the 1911 act came into operation on July 15, 1912. Dis¬ 
ablement benefit requires membership for 104 weeks, so that this 
feature came into the expenditures in July, 1914. Several changes 
were made in the maternity benefit and in the practice of the payment 
of sickness benefit to women in 1913 and 1914, so that comparisons 
with these years must be made with caution. 











































































































OPERATIONS OF THE SYSTEM. 


67 


The data of most interest in the table are those relating to the 
expenditure per member per week for benefits, which include only 
the years 1913 to 1915, for reasons already stated. The sickness 
benefit per week for men was highest in 1914 with 2.43d. (4.9 cents, 
par), and lowest in 1913 with 2.16d. (4.4 cents, par). The sickness 
and maternity benefit payments have been varied so much by changes 
in the law and in the practice of the societies that the figures for the 
different years are not comparable, but it is of interest to note that 
in Scotland the expenditure was decreasing from 1914 to 1916. 

The changes which the act of 1920 will cause in the expenditure 
for benefit were estimated by the Government actuary to be as 
follows: 

ESTIMATE OF EXPENDITURE FOR BENEFITS, JULY, 1920, TO JULY, 1921. 

[Source: Ministry of Health. National health insurance bill, 1920. Report by the Government actuary 
upon the financial provisions of the bill. London, 1920. Cmd. 612. (Page 9. £ at par=$4.8665.) 


At rates of benefit existing up to July 5,1920. 


Country. 

Approved societies. 

Deposit con¬ 
tributors. 

Total. 

Men. 

Women. 

England. 

£11,356,000 

1,556,000 

510,000 

856,000 

£4,804,000 

617,000 

235,000 

157,000 

£224,000 

27,000 

5,000 

10,000 

£16,384,000 

2,200,000 

750,000 

1,023,000 

Scotland. 

Ireland... . 

Wales.. . 

United Kingdom. 

14,278,000 

5,813,000 

266,000 

20,357,000 

F.npland . 

At new rates of benefit effective July 5, 1920, under act 
of May 20,1920. . 

£15,967,000 

2,190,000 

721,000 

1,202,000 

£6,786,000 

876,000 

341,000 

224,000 

£294,000 

34,000 

6,000 

12,000 

£23,047,000 

3,100,000 

1,068,000 

1,438,000 

Scotland . 

T rpl ?yn ft . 

Wales. 

TTnit.pd Kingdom. 

20,080,000 

8,227,000 

346,000 

28,653,000 

England .. 

Increase in expenditure after July 5,1920. 

£4,611,000 

634,000 

211,000 

346,000 

£1,982,000 

259,000 

106,000 

67,000 

£70,000 

7,000 

1,000 

2,000 

£6,663,000 

900,000 

318,000 

415,000 

Scotland. 

Ireland.. 

Wales. 

United Kingdom. 

5,802,000 

2,414,000 

80,000 

8,296,000 



According to these estimates, the total amount which would have 
been expended for pecuniary benefits under the rates of benefit 
used in the table on page 25 was £20,357,000 ($99,067,341, par) m 
1920: under the new rates of benefit, this amount is expected 
to be £28,653,000 ($139,439,825, par), an increase of £8,296,000 
($40,372,484, par), or about 41 per cent. The approved societies 
will pay the insured men about this per cent of increase, while for 
women the increase will be about 42 per cent. . 

The 1922 annual report of the chief medical officer of the Ministry 
of Health presents for the first time a summary of the expenditures 












































68 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


for sickness and for disablement benefits in England and Wales 
during the years 1913 to 1921. The data are as follows: 

EXPENDITURES OF APPROVED SOCIETIES (ENGLAND AND WALES) FOR SICKNESS 
AND DISABLEMENT BENEFITS, 1913 TO 1921. 


[Source: Annual report of the chief medical officer of the Minis try of Health for the year 1921. London, 
1922. Page 26. £ at par=$4.8665. The figures for 1920 and 1921 are subject to adjustment.] 


Year. 

Sickness benefit. 

Disablement benefit. 

Men. 

Women. 

Men. 

Women. 

19131. 

£3,623,220 

4,019,187 

3 3,141,548 

3 2 683,782 
3 2,463,196 
3 2,842,753 
3 3,066,342 
3,667,081 
4,810,470 

£1,770,371 

1,732,327 

1,393,402 

1,176,181 

1,157,523 

1,441,639 

1,319,201 

1,678,092 

2,271,662 



1914i. 

19151. 

19161. 

1917 . 

1918 . 

1919 . 

1920 * . 

1921 &. 

Total, 9 years. 

Average per annum. 

3 £124,212 
514,681 
655,241 
713,124 
739,029 
779,854 
1,104,621 
1,669,985 

3 £36,781 
210,573 
308,688 
358,783 
396,868 
434,499 
629,890 
981,746 

30,317,579 

13,940,398 

6,300,747 

3,357,828 

3,368,620 

1,548,933 

840,100 

447,710 


* The figures for 1913 to 1916 do not agree with those for England and Wales in the table on page 65, 
Which are taken from a different source. 

2 Disablement benefit became payable for the first time in July, 1914. 

. 8 These figures are lower than they would have been had not a considerable proportion of the total male 
insured population been serving with the Forces. The rise in years 1918-19 is attributable to the influ- 
enzaepidemic in those years and (1919) to the return of men from the Forces to civil life; toward the close 
of 1921 a further influenza epidemic caused an abnormal sickness experience in certain parts of England 
particularly in Yorkshire. 

4 During second half-year of 1920 higher rates of benefit under the National Health Insurance Act (1920) 
were paid. For comparison with previous years’ expenditure at the old rates, the figures for the year 
should be reduced by approximately 20 per cent (women’s sickness, approximately 22£ per cent). 

5 During second half-year of 1921 varying increased rates of benefit were paid as additional cash benefits 
by certain societies out of disposable surpluses declared at the first valuation. It has not been found 
possible at present to fix a reliable percentage as representing this increase, but, apart from this, for com¬ 
parison with previous years’ expenditure at the old rates in force prior to July, 1920, the figures for the 
year 1921 should be reduced by approximately 33$ per cent (women’s sickness benefit, approximately 


The report (page 27) makes the following comment on the table: 

From this table it is seen that the average amount (based on the figures for the last 
9 years) paid annually in England and Wales to men for sickness benefit was 
£3,368,620 [$16,393,389, par]. The corresponding amount paid for disablement 
benefit was £840,100 [$4,088,347, par]. Disregarding the increased rates of benefits 
paid by certain societies from July, 1921, by way of additional benefits out of their 
disposable surpluses on valuation, and taking the maximum ordinary rates of sickness 
and disablement benefit payable to men (namely, for sickness benefit 10s. [$2.43, par] 
per week prior to July 5, 1920, and 15s. [$3.65, par] per week after that date, and for 
disablement benefit 5s. [$1.22, par] per week and 7s. 6d. [$1.83, par] per week, respec¬ 
tively), these figures represent an average minimum of 6,217,927 weeks of sickness 
per annum under sickness benefit, and 2,945,686 weeks under disablement benefit, 
making a total of 9,163,613. For women, the corresponding figures represent an 
average annual minimum of 3,763,340 weeks’ sickness benefit and 1,549,121 disable¬ 
ment benefit, making a total of 5,312,461 weeks. 

Thus, at least 14,476,000 weeks’ work are lost on an average every year through 
sickness, or a period of upward of 278,000 years. That is to say, in England and 
Wales there is lost to the nation every year, among the insured population only, and 
excluding the loss due to sickness for which sickness or disablement benefit is not 
payable, the equivalent of the work of 278,000 persons v Moreover, it must be remem¬ 
bered that it is not only the working equivalent of 278,000 persons that the nation 
loses every year, but also the labor and expense involved in their care during the 
14,476,000 weeks of their incapacitation. To this loss of time and capacity among the 
14,000,000 insured persons we must, to obtain the national loss, add a comparable 
loss, though persumably not so large a proportional loss, in respect of the remaining 
23,000,000 persons (including children) which comprise the total population. 































OPERATIONS OF THE SYSTEM. 


69 


SANATORIUM BENEFIT. 

In the House of Commons on December 17, 1919, the Minister of 
Health frankly stated that in his opinion the results obtained by the 
sanatorium benefit under the insurance acts were not satisfactory to 
him and that it would take a generation before Great Britain could 
catch up with the needs of the population. Circumstances connected 
with the war, he stated, were largely the cause of the incomplete 
success of the measures inaugurated under the insurance acts for 
combating tuberculosis. The minister gave the following summary 
statement of the number of persons who had received sanatorium 
treatment in England and Wales: In 1914, 31,793; 1915, 29,741; 
1916, 29,850; 1917, 31,566; 1918, 35,430. 

A more complete statement of operations in the United Kingdom 
is given in the latest available report on tins feature of the insurance 
system. The following table shows the number of persons given 
treatment in the years 1917 and 1918: 

NUMBER OF INSURED PERSONS AND DEPENDENTS OF INSURED PERSONS RECEIV¬ 
ING SANATORIUM BENEFIT, AND NUMBER OF APPLICATIONS FOR SANATORIUM 
BENEFIT, 1917 AND 1918. 

[Source: National Health Insurance Joint Committee. Return as to the administration of sanatorium 
benefit, 1917-18. London, 1919. Cmd.232. Pages 3 and 6. In this table a person who received treatment 
within the period appears once, and once only, even though he received treatment in more tlian one 
form, except in the case of a person who, owing'to a change of residence during the period, received treat¬ 
ment under arrangements made by more than one committee. Persons whose course of treatment 
began prior to first of January and continued into the year following do not appear in the table for the 
succeeding year.] 


Country and sex. 

1917 

Number of applicants- 


Received treatment. 

Whose 
applica¬ 
tions 
were 
received 
before 
Jan. 1, 
but who 
did not 
receive 
treatment 
till on 
or after 
that 
date. 

Whose 

applica¬ 

tions 

were 

received 

during 

the 

period. 

Not 

recom¬ 

mended 

for 

reasons 
other- 
than 
those of 
health; 
e. g-, 
appli¬ 
cant not 
insured. 

Not 

treated 

for 

reasons 
such as 
those 
stated in 
foot¬ 
note. 1 

Pulmo¬ 

nary 

cases. 

Nonpul- 

monary 

cases. 

Total. 

England: 

Males. 

507 

20,890 

146 

2.073 

18,175 

1,003 

19,178 

Females. 

204 

9,504 

82 

806 

8,029 

851 

8,880 

Total. 

771 

30,394 

228 

2,879 

26,204 

1,854 

28,058 

Scotland: 

Males. 

72 

2,576 

155 

234 

2,188 

71 

2,259 

Females. 

42 

1,152 

84 

86 

956 

68 

1,024 

Total. 

114 

3,728 

239 

320 

3,144 

139 

3,283 

Ireland: 

Males. 

53 

2,096 

51 

202 

1,700 

196 

1,896 

Females. 

32 

1,507 

53 

138 

1,139 

209 

1,348 

Total. 

85 

3,603 

104 

340 

2,839 

405 

3,244 

Wales: 

Males 

581 

4,550 


2,888 

1,887 

356 

2,243 

Females. 

586 

2,602 


1,923 

940 

325 

1,265 

Total. 

1,167 

7,152 

.. . . 

4,811 

2,827 

681 

3,508 

United Kingdom: 

Males ... 

1,213 

30,112 

352 

5,397 

23,950 

1,626 

25,576 

Females. 

924 

14,765 

219 

2,953 

11,064 

1,453 

12,517 

Total. 

2,137 

44,877 

571 

8,350 

35,014 

3,079 

38,093 


i On expert examination found not to be suffering from tuberculous; removed to another area, and 
aecordinely do not appear as receiving treatment in the area in which application was first made, declined 
the treatment for which nominated; application under consideration on Dec. 31. 










































































70 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


NUMBER OF IOSURED PERSONS AND DEPENDENTS OF INSURED PERSONS RECEIV¬ 
ING SANATORIUM BENEFIT, AND NUMBER OF APPLICATIONS FOR SANATORIUM 
BENEFIT, 1917 AND 1918—Concluded. 



1918 


Number of applicants- 


Received treatment. 

Country and sex. 

Whose 
applica¬ 
tions 
were 
received 
before 
Jan. 1, 
but who 
did not 
receive 
treatment 
till on 
or after 
that ‘ 
date. 

Whose 

applica- 

tions 

were 

received 

during 

the 

period. 

Not 

recom¬ 

mended 

for 

reasons 
other 
than 
those of 
health; 

e. g. ? 
appli¬ 
cant not 
insured. 

Not 

treated 

for 

reasons 
such as 
those 
stated in 
foot¬ 
note. 

Pulmo¬ 

nary 

cases. 

Nonpul- 

monary 

cases. 

Total. 

England: 

Males. 

1,023 

348 

24,904 

9,475 

506 

2,465 

21,869 

1 0S7 

22,956 

Females. 

149 

785 

8,104 

785 

8^889 


Total. 

1,371 

34,379 

655 

3,250 

29,973 

1,872 

31,845 


Scotland: 

Males. 

93 

3,013 

1,065 

175 

441 

2,414 

76 

2,490 

934 

Females. 

30 

57 

104 

862 

72 


Total. 

123 

4,078 

232 

545 

3,276 

148 

3,424 


Ireland: 

Males. 

87 

2,132 

1,082 

41 

429 

1 526 

223 

1 749 

Females. 

66 

45 

165 

771 

167 

938 


Total. 

153 

3,214 

86 

594 

2,297 

390 

2,687 


Wales: 

Males. 

765 

5,296 

2,528 


3,665 

2,010 

2 019 

377 

2,396 

Females. 

671 


911 

278 

1,189 



Total. 

1,436 

7,824 


5,675 

2,930 

655 

3,585 



United Kingdom: 

Males. 

1,968 

1,115 

35,345 
14,150 

722 

7,000 

27,828 
10,648 

1,763 

1,302 

29 591 

Females. 

• 251 

3,064 

11,950 


Total. 

3,083 

49,495 

973 

10,064 

38,476 

3,065 

41,541 



As no information is available as to the whole number of insured 
persons suffering from tuberculosis, it is not possible to make any 
comparison which would show how completely the treatment af¬ 
forded met the needs of the insured population. In the House of 
Commons debates already referred to, the minister stated that all 
persons recommended for treatment were receiving it, but that the 
question of securing proper treatment for each case at a sufficiently 
early stage is dependent upon a correct diagnosis being made and 
upon the willingness of the patient to accept the appropriate form 
of treatment in the early stages of the disease. 

The class of treatment (residential, dispensary, and home treat¬ 
ment) afforded to the insured persons in 1917 and 1918 is as follows: 




























































OPERATIONS OF THE SYSTEM. 


71 


NUMBER OF CASES OF TUBERCULOSIS RECEIVING TREATMENT DURING 1917 AND 1918. 


Insurance Joint Committee. Return as to the administration of sanatorium 
■’ London, 1919. Cmd. 232. Pages 3 and 6. A person receiving treatment under more 

t an orie heading appears in this table as a separate case under each heading. Persons whose treat¬ 
ment began before Jan. 1 and continued into the year following are included.] 


Coimtry and sex. 

1917 

1918 

Residential. 

Dispensary. 

Domiciliary. 

Residential. 

Dispensary. 

Domiciliary. 

England: 

Males. 

16,582 

7,372 

19,314 

10,615 

23,638 

12,475 

19,925 
7,336 

24,365 

11,189 

27,881 
12,864 

Females. 

Total. 

23,954 

29,929 

36,113 

27,261 

35,554 

40,745 

Scotland: 

Males. 

2,409 

1,056 

269 

163 

616 

362 

2,553 

943 

395 

154 

773 

390 

Females. 

Total. 

3,465 

432 

978 

3,496 

549 

1,163 

Ireland: 

Males. 

1,381 

564 

501 

421 

1,463 

1,883 

1,388 

492 

607 

404 

1,590 

1,877 

Females. 

Total. 

1,945 

922 

3,346 

1,880 

1,011 

3,467 

Wales: 

Males. 

2,006 

1,085 

2,138 
1,701 

1 ,7i£ 

9oo 

1,990 

1,008 

2,386 

1,610 

1,837 

1,053 

Females. 

Total. 

3,091 

3,839 

2,665 

2,998 

3,996 

2,890 

United Kingdom: 

Males. 

22,378 

10,077 

22,222 

12,900 

27,427 
15,675 

25,856 

9,779 

27,753 
13,357 

32,081 
16,184 

Females. 

Total. 

32,455 

35,122 

43,102 

35,635 

41,110 

48,265 



The results of the treatment provided the cases enumerated in 
the preceding table were as follows: 

ANALYSIS OF CASES OF DISPENSARY AND RESIDENTIAL TREATMENT, 1917 AND 1918. 


[ Source: National Health Insurance Joint Committee. Return as to the administration of sanatorium 
benefit. 1917-18. London, 1919. Cmd. 232. Pages 4 and 7. The figures in columns 2, 3, and 5 do not 
show the number of cases in which the treatment of the patient was concluded, since, after ceasing to 
attend the dispensaries, patients may receive continued treatment in other forms. The figures in col¬ 
umn 5 relate to cases as to the progress of which no definite report is available for various reasons, e. g., 
the withdrawal from the dispensary treatment of the insured persons themselves before the expiration 
of the period recommended.] 


Dispensary treatment. 



1917 

1918 

Country and sex. 

Total 

Discharged 

from 

institution. 


Treat¬ 

ment 

discon¬ 

tinued 

in 

other 

cases. 

Still 

under 

treat¬ 

ment 

on 

Jan. 1, 
1918. 

Total 

Discharged 

from 

institution. 


Treat¬ 

ment 

discon¬ 

tinued 

in 

other 

cases. 

Still 

under 

treat¬ 

ment 

on 

Jan. 1, 
1919. 

cases 

treat¬ 

ed. 

Im¬ 

prov¬ 

ed. 

With¬ 

out 

im¬ 

prove¬ 

ment. 

Died. 

cases 

treat¬ 

ed. 

Im¬ 

prov¬ 

ed. 

With¬ 

out 

im¬ 

prove¬ 

ment. 

Died. 


(1) 

(2) 

(3) 

(4) 

(5) 

(6) 

(1) 

(2) 

(3) 

(4) 

(5) 

(6) 

England: 

Males. 

19,314 

2,278 

985 

1,508 

1,998 

12,545 

24,365 

2,438 

1,003 

480 

1,674 

795 

2,140 

870 

17,050 

7,747 

Females. 

10; 615 

L385 

543 

'673 

1,066 

6^ 948 

ll’ 189 

1,297 




Total. 

29,929 

3,663 

1,528 

2,181 

3,064 

19,493 

35,554 

3,735 

1,543 

2,469 

3,010 

24,797 




Scotland: 

Males. 

269 

57 

15 

23 

13 

161 

395 

81 

19 

22 

19 

254 

Females. 

163 

41 

3 

11 

5 

103 

154 

21 

10 

13 

8 

102 





Total. 

432 

-. 

98 

- 

'1 

18 

34 

-- 

18 

254 

549 

192 

29 

35 

27 

355 









































































































72 NATIONAL HEALTH INSURANCE IN GRfiAT BRITAIN. 


ANALYSIS OF CASES OF DISPENSARY AND RESIDENTAL TREATMENT, 1917 AND 1918— 

Concluded. 


■ 

Dispensary treatment. 


1917 

1918 



Discharged 





Discharged 






from 





from 






institution. 


Treat- 

Still 


institution. 


Treat- 

Still 

Country and sex. 





ment 

under 





ment 

under 






discon- 

treat- 

1 OlHI 




discon- 

treat- 


cases 

treat- 


With- 

Died. 

tinued 

ment 

cases 

treat- 


With- 

Died. 

tinued 

ment 


ed. 

Im- 

out 


in 

other 

on 

Jan. 1, 

ed. 

Im- 

out 


in 

other 

on 

Jan. 1, 



prov¬ 

ed. 

im¬ 

prove- 


cases. 

1918/ 


prov¬ 

ed. 

im¬ 

prove- 


cases. 

1919. 




ment. 






ment. 





(1) 

(2) 

( 3 ) 

(4) 

(5) 

(6) 

(1) 

(2) 

( 3 ) 

(4) 

(5) 

(6) 

Ireland: 













Males. 

501 

95 

14 

34 

126 

232 

607 

145 

17 

39 

163 

243 

Females. 

421 

76 

9 

18 

141 

177 

404 

87 

13 

19 

118 

167 

Total. 

922 

171 

23 

52 

267 

409 

1,011 

232 

30 

58 

281 

410 

Wales: 













Males. 

2,138 

633 

175 

68 

95 

1,167 

2,386 

863 

149 

85 

140 

1,149 

Females. 

1,701 

509 

122 

56 

58 

956 

1,610 

579 

109 

73 

86 

763 

Total. 

3,839 

1,142 

297 

124 

153 

2,123 

3,996 

1,442 

258 

158 

226 

1,912 

United Kingdom: 













Males. 

22,222 

3,003 

1,189 

1,633 

2,232 

14,105 

27,753 

3,527 

1,248 

1,820 

2,462 

18,696 

Females. 

12,900 

2,011 

677 

758 

1,270 

8,184 

13,357 

1,984 

612 

'900 

L0S2 

8 ,779 

Total. 

35,122 

5,074 

1,806 

2,391 

3,502 

22,289 

41,110 

5,511 

1,860 

2,720 

3,544 

27,475 


Residential treatment. 

England: 













Males. 

16,582 

9,328 

1,813 

1,140 

841 

3,460 

19,925 

11,624 

2,410 

1,194 

848 

3,848 

Females. 

7,372 

4,317 

795 

412 

237 

1,611 

7,336 

4,127 

961 

'479 

162 

1 ,608 

Total. 

23,954 

13,645 

2,608 

1,552 

1,078 

5,071 

27,261 

15,751 

3,371 

1,673 

1,010 

5,456 

Scotland: 













Males. 

2,409 

1,099 

284 

328 

153 

545 

2,553 

1,044 

275 

311 

194 

729 

Females. 

1,056 

504 

134 

124 

25 

269 

943 

413 

113 

136 

32 

249 

Total. 

3,465 

1,603 

418 

452 

178 

814 

3,496 

1,457 

388 

447 

226 

978 

Ireland: 













Males. 

1,381 

G85 

194 

132 

108 

202 

1,388 

704 

208 

141 

87 

188 

Females. 

564 

302 

74 

53 

23 

112 

492 

271 

87 

52 

17 

65 

Total. 

1,945 

987 

268 

185 

131 

374 

1,880 

1,035 

295 

193 

104 

253 

Wales: 













Males. 

2,006 

1,118 

114 

134 

214 

426 

1,990 

1,082 

125 

154 

232 

397 

Females. 

1,085 

539 

100 

62 

105 

279 

1,008 

526 

81 

44 

107 

250 

Total. 

3,091 

1,657 

214 

196 

319 

705 

2,998 

1,608 

206 

198 

339 

647 

United Kingdom: 













Males. 

22,378 

12,230 

2,405 

1,734 

1,316 

4,693 

25,856 

14,514 

3,018 

1,800 

1,361 

5 102 

Females. 

10,077 

5,662 

1,103 

651 

390 

2,271 

9,779 

5,337 

L242 

711 

'318 

2,172 

Total. 

32,455 

17,892 

3,508 

2,385 

1,706 

6,964 

35,635 

19,851 

4,260 

2,511 

1,679 

7,334 


It will be noted that the results of the treatment are stated with 
reserve; none is reported as “cured” but only as “improved” at the 
conclusion of treatment. 

The total amounts expended by the insurance committees in their 
administration of the sanatorium benefit in 1917 and 1918 were as 
follows: 































































































OPERATIONS OF THE SYSTEM. 


73 


APPROXIMATE EXPENDITURE OF INSURANCE COMMITTEES ON THE PROVISION OF 
SANATORIUM BENEFIT, INCLUDING PAYMENTS TO PRACTITIONERS IN RESPECT 
OF DOMICILIARY TREATMENT, BUT EXCLUDING THE COST OF ADMINISTRATION, 
1917 AND 1918. ’ 


[Source: National Health Insurance Joint Committee. Return as to the administration of sanatorium 
benefit, 1917-18. London, 1919. Cmd. 232. Pp. 5 and 7. £ at par=$4.8665.] 


Year. 

England. 

Scotland. 

Ireland. 

Wales. 

United 

Kingdom. 

1917. 

£619,000 

664,000 

£93,000 

10.5,000 

£42,000 

42,000 

£42,000 

JQ OOO 

£796,000 

854,000 

1918. 




These sums represent only the expenditures of the insurance com¬ 
mittees for the insured persons. In the House of Commons on Decem¬ 
ber 17, 1919, the Minister of Health stated that the total expenditures 
in England and Wales by public authorities during the year ending 
March 31, 1918, for the total population, was approximately 
£1,550,000 ($7,543,075, par). In the above table the expenditure in 
England and Wales in the calendar year 1917 was £661,000 
($3,216,757, par) for the insured population. Presumably “public 
authorities” does not include the insurance committees, so that the 
two countries show an expenditure of over £2,000,000 ($9,733,000, 
par) for the relief of tuberculosis in 1917. 

As stated before, the Minister of Health regards the provision of 
facilities for treating tuberculosis as insufficient, a large part of the 
shortage being due to causes connected with the war; presumably 
he referred to the fact that practically all building was suspended 
after August, 1914, and the contemplated chain of sanatoriums which 
Mr. Lloyd George in 1911 said would be constructed was never 
realized. However, the actual number of beds in use for insured 
persons is at least a substantial number, as the following table shows: 

SUMMARY OF INSTITUTIONAL PROVISION: ENGLAND, SCOTLAND, AND IRELAND, 

1917 AND 1918. 


[Source: National Health Insurance Joint Committee. Return as to the administration of sanatorium 
benefit, 1917-18. London, 1919. Cmd. 232. Pp. 5 and 8.] 


Country and year. 

(1) 

Number of 
beds to 
which in¬ 
surance 
committees 
were en¬ 
titled under 
permanent 
arrange¬ 
ments. 

(2) 

Number of beds re¬ 
served to insurance 
committees under 
provisional arrange¬ 
ments with— 

(3) 

Total number of beds 
for insured and non¬ 
insured in— 

(4) 

Number of 
approved 
tuberculo¬ 
sis dis¬ 
pensaries. 


Local au¬ 
thorities. 

Voluntary 
institu¬ 
tions direct. 

Local au¬ 
thorities’ 
institu¬ 
tions. 

Voluntary 

institu¬ 

tions. 

England: 




6,163 

5,937 

373 

1917. 

3,564 

387 

309 

1918. 

Scotland: 

3; 517 

437 

248 

6,749 

6,385 

375 

1917. 

437 

137 

28 

2,051 

647 

23 

1918. 

445 

142 

24 

2,121 

671 

23 

Ireland: 





2,251 


1917. 

249 

14 

6 

2,176 

175 

1918. 

250 

16 

24 

3,171 

3,262 

180 


The numbers shown in columns (1) and (2) represent accommodation secured under general arrangements 
as distinct from arrangements for individual patients. In addition to the accommodation so secured, 
beds are obtained by insurance committees for individual patients as and when required out of the total 
approved accommodation (figures of which are given in column (3)) available for the treatment of persons 
suffering from tuberculosis, whether insured or noninsured. 

In the case of England, the figures in all columns are stated as of Jan. 1,1918 and 1919. The figures in 
columns (3) and (4) are supplied by the local government board and represent minimum figures for the 

In the case of Scotland, the figures in all columns are stated as of Dec. 31,1917; and in the case of Ireland 
as of Jan. 1, 1918. The figures for Ireland in column (3) represent beds not specially reserved for the 
treatment of tuberculosis. 





































74 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


SUMMARY OF INSTITUTIONAL PROVISION: WALES, 1917 AND 1918. 

[Source: National Health Insurance Joint Committee. Return as to the administration of sanatorium 
benefit, 1917-18. London, 1919. Cmd. 232. * Pages. 5 and 8.] 


December. 

Number of 
beds be¬ 
longing to 
or rented 
by the K. 
E. S. W. 
N. M. As¬ 
sociation. 

Total number of beds 
rented by the K. E. 
S. W. N. M. Asso¬ 
ciation in— 

Total num¬ 
ber of beds 
belonging 
to the K. 
E. S. W. 
N. M. As¬ 
sociation. 

Total num¬ 
ber of ap¬ 
proved dis¬ 
pensaries. 

Total num¬ 
ber of visit¬ 
ing sta¬ 
tions. 

Local au¬ 
thorities’ 
institu¬ 
tions. 

Voluntary 

institu¬ 

tions. 

1917. 

965 

1,012 

88 

85 

121 

101 

756 

836 

14 

13 

86 

81 

1918. 



Note. —In Wales, the provision of treatment for insured and noninsured persons suffering from 
tuberculosis was undertaken by the King Edward VII Welsh National Memorial Association under agree¬ 
ments with all the Welsh insurance committees and arrangements with 16 (out of 17) Welsh county and 
county borough councils. The number of beds available for insured persons can not be given separately 
and the figures for Wales in the appended table represent the beds available for insured and noninsured. 
The figures in all columns are for December. 

} 

According to a statement in a review of the insurance system 
(published in the New Statesman, March 14, 1914, Supplement, p.23), 
the proportion of beds to population should be about one per thousand; 
perhaps this ratio should not be used for insured persons, because of 
the high rates of tuberculosis during the early wor kin g years of life, 
but if it is taken as approximately correct, then the 12,000,000 
insured persons in England had about 4,200 beds reserved for them 
in 1918 by the insurance committees, or approximately one-third of 
the standard above mentioned. The table following, however, shows 
that some of the facilities available for both insured and noninsured 
persons were used by the committees for those entitled to sanatorium 
benefit. 


APPROXIMATE NUMBER OF BEDS OCCUPIED AT ONE TIME BY INSURANCE COM¬ 
MITTEE'S PATIENTS IN 1918. 

[Source: National Health Insurance Joint Committee. Return as to the administration of sanatorium 
benefit, 1917-18. London, 1919. Cmd. 232. Page 8.) 


Country. 


England.. 
Scotland 1 . 
Ireland... 
Wales.... 


Total. 


Discharged 
soldiers, 
etc., en¬ 
titled to 
priority of 
residential 
treatment. 

Other per¬ 
sons en¬ 
titled to 
sanatorium 
benefit. 

Total. 

1.915 

3,940 

5,855 

365 

646 

1,011 

85 

310 

395 

148 

576 

724 

2,513 

4,572 

7,985 


For Scotland, the figures are stated for Dec. 31,1918. 


FINANCIAL OPERATIONS. 

SUMMARY OF RECEIPTS AND EXPENDITURES. 

In connection with an inquiry from a member of Parliament, the 
following statement of the total amount expended on benefits and on 
administration, from 1911 to 1918, was presented and published in 
House of Commons Debates, April 7, 1919. 







































OPERATIONS OF THE SYSTEM. 


75 




[£ at par=$4.8665.] 


Country. 

Moneys 
provided by 
Parliament. 

(a) 

Moneys from 
contri¬ 
butions. 

(b) 

Total. 

(c) 

England. 

Wales. . 

SentEnrl *.------. . 

£29,200,000 
2,100,000 
4,200,000 
2,300,000 
2,200,000 

£51,800,000 
3,700,000 
7,200,000 
2,300,000 

£81,000,000 
5,800,000 
11,400,000 
4,600,000 
2,200,000 

Ireland. . 

Joint committee working in all parts of the United Kingdom.. 

Total. 

40,000,000 

65,000,000 

105,000,000 

_ 


(guidttdeB (1) aU expenditures from moneys provided by Parliament under 
S^°o^ 3 iqii 16 b ^ 6, , 49 t 53 » and 81 (!0) and. (11) of the national insur- 

TQFS fsnVhpn Vrw ^ Ctl0 + 3 S 2 \? f * be natlona ! insurance (Part I amendment) act, 
1915 (subhead G of the vote for the joint committee, subheads F, G, H, J, and L of 

;^r te8 + - th ? Se ^ 1 ^ ance . ^missions); (2) all the supplementary grants 
under sections 1 and 31 of the national insurance act, 1913, and sections 2 and 4 of 
the national health insurance act, 1918 (subheads A to F of the national health insu- 
? n a? <®P£ Cial grants) vote for the years 1912-13 and 1913-14, subheads E, F, and H 

to JN 01 the vote for the mint. rnmrmttoo on A XT -_ . i 



committee, subheads A to E of the votes for the several insurance commissions' and 
sundry subheads of the votes for various other Government departments e c office 
of works, stationery office, post office, etc.). 

(b) and (c) include expenditure from the joint contributions of employers and 
employed persons (of which it is estimated that 55 per cent is paid by the employed 
persons), and such small amount of expenditure as can properly be considered to 
have been met from interest on investments. 


Included in column (a) are sums amounting to approximately 
£2,380,000 ($11,582,270, par) which have been spent From moneys 
provided by Parliament for the extension of sanatorium benefit to 
dependents of insured persons under section 17 of the national insur¬ 
ance act, 1911, and for the treatment of tuberculosis generally. 

In addition to the above there are sums of £300,000 ($1,459,950, 
par) from the exchequer and £66,000,000 ($321,189,000, par) from the 
contributions that have been placed in reserve and invested, under 
section 4 of the national health insurance act, 1918, and section 56 of 
the national insurance act, 1911, respectively, to meet future liabili¬ 
ties. 

According to this statement, out of the £105,000,000 ($510,982,500, 
par) expended on the system, Parliament provided £40,000,000 
($194,660,000, par), or 38 per cent, and the employers and insured 
persons provided 62 per cent. This statement, however, should be 
considered in connection with the fact that these amounts are expen¬ 
ditures and not receipts. The paragraph above shows that £66,000,- 
000 ($321,189,000, par) from contributions have been placed in the 
reserves to meet future liabilities; the amount from contributions 
placed in the reserve is apparently slightly more than is expended for 
benefits and administration. 

There is not available a similar statement as to the receipts of the 
system since its commencement, but the following summary state¬ 
ment shows the amount received and expended in England during the 
year 1920. 
























76 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


Summary of Approximate Receipts and Payments Under the National Health 
Insurance Acts (England) for the Year 1920. 6 

[£ at par = $4.8665.] 


Accumulated funds at beginning of year: 

Invested with national debt commissioners. £39,168,000 

Investments made by or on behalf of approved societies... 20,954,000 

Cash at Bank of England. 361,000 

Cash in hands of approved societies and insurance committees. 1,137,000 

Receipts: 

Contributions of employers and employed persons. 18,815,000 

Exchequer (including statutory proportion of benefits, sundry 

grants-in-aid, and cost of central administration)... 7, 728,000 

Interest and sundry receipts... 2,787,000 


90,950,000 

Payments: 

Medical and sanatorium benefits (including £7,159,000 remuner¬ 


ation of medical practitioners). 9, 217,000 

Sickness, disablement, and maternity benefits... 8, 353,000 

Administration expenses— 

Approved societies. £2,646,000 

Insurance committees. 437,000 

Central administration. 660,000 


Accumulated funds at end of year: 

Invested with national debt commissioners. 41, 618,000 

Investments made by or on behalf of approved socie¬ 
ties. 25,073,000 

Cash at Bank of England.. 936,000 

Cash in hands of approved societies and insurance 

committees. 2,010,000 

- 69,637,000 


90,950,000 

Expenditure in connection with national health insurance in 
England is also incurred by other Government departments in 
respect of office accommodation (buildings, furniture, fuel, and light), 
rates, stationery and printing, postage, telegrams, telephones, 
national insurance audit department, and miscellaneous services. 
The estimated cost of these services in 1920 was £435,000 ($2,116 - 
928, par). 

RESERVES ON MARCH 31, 1920. 

The reserves which have been gradually accumulating under the 
regulations of the system had reached the following sums on March 
31, 1920, according to House of Commons Debates, June 3, 1920, 
page 2085: 

[£ at par=$4.8665.] 

The moneys accumulated under the national health insurance acts up to March 31 
1920, are as follows: 

Investments in the hands of approved societies or invested on their 


behalf in securities selected by them (under sec. 56 of the national 

insurance act, 1911) (cost)... £29,000,000 

Investments in the hands of the national debt commissioners (under 

sec. 54 of the national insurance act, 1911) (cost). 47, 500,000 

Balances of cash in the several national health insurance funds and in 
the hands of approved societies and insurance committees. 1, 500,000 


Total...... 78,000,000 


‘Ministry of Health. Second annual report, 1920-21. Cmd. 1446. P.210. 































OPERATIONS OF THE SYSTEM. 


77 


INCOME IN 1920. 

The income of the system in the year 1920 under the rates of con¬ 
tribution prior to the enactment of the 1920 law, and the income 
under the new rates, were estimated by the Government actuary as 
follows: 

ESTIMATED ANNUAL CONTRIBUTIONS BEFORE AND AFTER JULY 5, 1920. 

[Source: Ministry of Health. National health insurance bill. 1920. Report by the Government actuary 
upon the financial provisions of the bill. London, 1920. ' Cmd. 612. Page 6. £ at par=$4.8665.] 


Country. 

Before July 5, 1920. 

After July 5, 1920. 

Increase. 

Employers. 

Insured 

persons. 

Employers. 

Insured 

persons. 

Employers. 

Insured 

persons. 

England. 

£7,388,000 

1,002,000 

373,000 

462,000 

£9,082,000 
1,232,000 
397,000 
589,000 

£12,314,000 

1,670,000 

596,000 

770,000 

£11,545,000 
1,566,000 
5*6,000 
743,000 

£4,926,000 
668,000 
223,000 
308,000 

£2,463,000 
334,000 
149,000 
154,000 

Scotland. 

Ireland. 

Wales. 

United Kingdom. 

9,225,000 

11,300,000 

15,350,000 

14,400,000 

6,125,000 

3,100,000 


Note. —The normal division of the contributions is varied in respect of low-wage earners, the em¬ 
ployers paying more and the insured persons less, with, in some cases, a State grant of Id. (2 cents, par) a 
week. In the absence of information as to the number of persons falling within this category, winch in 
any event must in present circumstances be very small, no account has been taken of this provision in 
estimating the respective totals of contributions payable. 

For the purpose of this table the number of contributors, is taken as 350,000 fewer than the number of 
insured persons, this difference representing persons who, having left insurable employment, remain en¬ 
titled to benefits for the ensuing 12 months. Women who have left employment on marriage constitute 
a large proportion of this number. 

In view of the very small number of voluntary contributors it has been assumed in the preparation of 
this table that all insured persons are employed contributors. 

The increase in the amounts which Parliament will provide are 
contained in the following statement: 

ESTIMATE OF GRANTS FROM NATIONAL TREASURY, 1920 (EXCLUSIVE OF SPECIAL 

GRANTS TO MEDICAL SERVICES). 

[Source: Ministry of Health. National health insurance bill, 1920. Report by the Government actuary, 
upon the financial provisions of the bill. London, 1920. Cmd. 612. Page 10. £ at par= $4.8665.J 


Country. 

At rates of benefit prior to July 5, 1920. 

Approved societies. 

Deposit 

contributors. 

Total. 

Men. 

Women. 

England. 

£2,523,000 

346,000 

147,000 

190,000 

£1,201,000 
154,000 
79,000 
39,000 

£51,000 
6,000 
2,000 
2,000 

£3,775,000 

506,000 

228,000 

231,000 

Scotland. 

Ireland . 

Wales. 

United Kingdom . 

3,206,000 

1,473,000 

61,000 

4,740,000 

280,000 

150,000 

Supplementary grants: 

WomPn’s equalization fund.. 

Central fund . 




Total . 







5,170,000 

England . 




At rates of benefit under act of May 20, 1920. 

£3,549,000 

487,000 

206.000 

267,000 

£1,509,000 

195,000 

100,000 

49,000 

£66,000 

8,000 

3,000 

3,000 

£5,124,000 

690,000 

309,000 

319,000 

fgpotland . 

Ireland _ . 

Wales. 

United Kingdom. 

4,509,000 

1,853,000 

80,000 

6,442,000 

350,000 

150,000 

Supplementary grants: 

P.pn t ra 1 fnrud 




Total . 







6,942,000 






J04936 0 —23—Bull. 312-6 





































































78 NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


ESTIMATE OF GRANTS FROM NATIONAL TREASURY, 1920 (EXCLUSIVE OF SPECIAL 
GRANTS TO MEDICAL SERVICES)—Concluded. 


Increase in expenditure after July 5,1920, due to 
act of May 20, 1920. 


Country. 

Approved societies. 

Deposit 

contributors. 

Total. 

Men. 

Women. 

England. 

£1,026,000 

141,000 

59,000 

77,000 

£308,000 
41,000 
21,000 
10,000 

£15,000 

2,000 

1,000 

1,000 

£1,349,000 
184,000 
81,000 
88,000 

Scotland. 

Ireland. 

Wales. 

United Kingdom. 

Supplementary grants: 

Women's equalization fund. 

1,303,000 

380,000 

70,000 

19,000 

1,702,000 

70,000 

Central fund.. 



Total. 





1,303,000 

450,000 

19,000 

1,772,000 



The amounts given in the first table on page 77 show that the income 
from contributions will be increased from £20,525,000 ($99,884,912.50, 
par) to £29,750,000 ($144,778,375, par), or 45 percent; the income from 
Parliament (excepting certain special grants) will be increased from 
£4,740,000 ($23,067,210, par) to £6,442,000 ($31,349,930, par), or 
36 per cent. 

NATIONAL HEALTH INSURANCE FUND. 

It will be recalled that the receipts of the insurance system are 
placed in an account called the national health insurance fund, on 
which the societies draw to pay benefits and administration expenses. 
In the reports of the insurance system, the statements of the receipts 
and expenses of these funds—one for each of the four countries—are 
given separately and with a number of variations in the four accounts. 
The only consolidated statement available is that for the period end¬ 
ing January 11,1914, given in the Abstract of Labor Statistics for 1915 
(the latest published up to January 1, 1921). This statement is as 
follows: 

RECEIPTS AND PAYMENTS OF NATIONAL HEALTH INSURANCE FUND, JULY 15, 1912, 

TO JANUARY 11, 1914. 


[Source: Seventeenth Abstract of Labor Statistics of the United Kingdom. London, 1915. Cd. 7733. 

Page 168. £ at par= $4.8665.] 


Item. 

England. 

Wales. 

Scotland. 

Ireland. 

United 

Kingdom. 

RECEiPTS. 

From sale of health insurance stamps: 

At post offices. 

At board of trade labor exchanges. ... 

To army council.. 

To army (India). 

£19,783,000 

134,610 

78,798 

65,888 

115,096 

1,827,725 

3,868 

1,852 

100,000 

14,682 

4,535,777 

323 

£1,080,000 

13,096 

£2, 847,934 
43,655 
1,072 

£983,000 
225 
9,087 

£24,693,934 
191,586 
88,957 
65,888 
118,427 

2,371,195 

3,868 

2,419 

108,098 
14,682 
5,765.250 
1,002 

To other Government departments.... 
To employer depositors, quarterly and 

weekly stamping. 

To employers' sales of high value 
stamps. 

349,411 

855 

140,066 

2,476 

53,993 

To sundry persons by insurance com¬ 
missioners ... 

Admiralty contributions on behalf of 

sailors and marines. 

Mercantile marine exempt persons. 

223 

5,336 

142 

2,762 

202 

Exchequer grants. 

Other receipts. 

Total. 

293,852 
55 

651,149 
449 

284.472 
175 

26,661,619 

1 

1,741,973 

3,688,084 

1,333,630 

. 

33,425,306 



















































OPERATIONS OF THE SYSTEM. 


79 


RECEIPTS AND PAYMENTS OF NATIONAL HEALTH INSURANCE FUND, JULY 15, 1912, 

TO JANUARY 11,1914.—Concluded. 


Item. 


England. 


PAYMENTS. 


Wales. 


Scotland. 


Ireland. 


United 

Kingdom. 


Issues to: 

Approved societies for sickness and 
maternity benefits and for adminis¬ 
tration expenses (less refunds). 

Approved societies for investment. 

Insurance committees for sanatorium 
and medical benefits and for admin¬ 
istration expenses. 

Deposit contributors for sickness and 

maternity benefits (less refunds). 

Navy and army insurance fund for 
sickness and maternity benefits (less 

refund). 

Employer depositors, quarterly and 

weekly stamping, deposits repaid. 

Refunds on account of health insurance 

stamps returned to commissioners. 

For purchase of investments on behalf of 

approved societies. 

Other payments. 

Balance in hands of national debt com¬ 
missioners: 

For investment account.. 

For temporary investment.. 

Balance at bank.. 

Total. 


8,774,909 

870,519 


4,623,287 

15,727 

2,567 

15,518 

12,852 

34,856 

10,512 

1,642,499 

10,457,501 

200,872 


26,661,619 


642,460 

23,660 


286,350 

983 


977 

574 

585 

171 

43,443 

697,527 

45,243 


1,741,973 


1,230,000 

8,069 

608,473 

1,306 


1,835,000 
i 1,564 


3,688,084 


632,707 


36,078 

389 


21,702 


637,500 
3,843 


1,333,630 


11,280,476 

902,248 


5,554,188 

18,405 

2,567 

17,044 

14,794 

35,441 

35,151 

1,685,942 
13,627,528 
251,522 


33,425,306 


506 43 

_ 1,368 


2,766 


1 Including £107 cash on hand. 


The total receipts of the first period of actual operation (benefits 
were payable only after January, 1913) were £33,425,306 ($162,664,- 
252, par), of which £24,693,934 ($120,173,030, par) came from con¬ 
tributions (stamps sold), while the parliamentary grant was £5,765,- 
250 ($28,056,589, par). 

The disablement benefit was not payable during this period, so that 
the only pecuniary benefits included in the expenditures were sick¬ 
ness and maternity benefits, on which £11,280,476 ($54,896,436, par) 
were spent, including administration. The medical and sanatorium 
benefits required £5,554,188 ($27,029,456, par), including adminis¬ 
tration costs. The balance/for investment was larger in this period 
than later because the full demands for benefits had not been felt. 

The following summary gives the totals for the period 1912 to 1916 
for England alone: 


SUMMARY OF RECEIPTS AND EXPENDITURES OF THE NATIONAL HEALTH 
INSURANCE FUND OF ENGLAND. 1912 TO 1916. 


fSource - National Health Insurance Joint Committee. Report for 1913-14 on the administration 
of national health insurance. Cd. 7496. Page 503. National health insurance fund accounts for 
period Jan. 12 to Dec. 31, 1914. House of Commons Paper 38 of 1917, page 2. National Health In¬ 
surance Joint Committee. Report on the administration of national health insurance during the years 
1914-1917. Cd. 8890. Page 256. £ at par=$4.8665; shilling=24.3 cents; penny=2.03 cents.] 


Period. 

Receipts. 

Expenditures. 

Tnlvl^ 1912 tn Tar. 11 1914 . 

£ s. d. 

26,661,618 15 7 

18,305,962 11 Hi 
20,438,129 7 3i 

19,016,790 0 6i 

£ s. d. 

14,360,746 11 5 

18,071,611 16 2 

20,159,712fc 4 10 
18, 881, 84<T 19 H 

Tnn lOfn Dpp 31 1914 . 
























































80 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN 


The years 1915 and 1916 were affected by war conditions to such an 
extent that the operations here stated can not be considered normal. 

The first annual report of the Ministry of Health, Part IV, national 
health insurance (Cmd. 913), presents an abstract statement of the 
national health insurance fund of England for the three years 1917 to 
1919. The receipts and payments of the English fund are given as 
typical of the operation of the system, especially as the great majority 
of the insured persons reside in England. To this statement have 
been added the figures for the year 1920, taken from the second annual 
report of the Ministry of Health (Cmd. 1446). The two statements 
are as follows: 

ABSTRACT OF CASH RECEIPTS OF THE NATIONAL HEALTH INSURANCE FUND OF 
ENGLAND FOR THE YEARS 1917, 1918, 1919, AND 1920. 

[Source: First annual report of the Ministry of Health, 1919-20. Part IV. Administration of national 
health insurance (1917 to March 31, 1920). ' Page 78. Second annual report of the Ministry of Health, 
1920-21. Cmd. 1446. Page 208. £ at par = $4.8665.] 


Item. 


Balance brought forward from previous year. 

From sale of health insurance stamps: 

At post offices. 

At Ministry of Labor employment exchanges. 

To other Government departments. 

To employer depositors—Half-yearly and weekly 

. stamping. 

To employers—Bulk sales. 

To sundry persons by insurance commissioners. 

Postmaster General for postage stamps affixed to health 

insurance cards... 

Ministry of Labor for unemployment stamps affixed to 

healtn insurance cards... 

Contributions on behalf of seamen, marines, soldiers, 

and airmen. 

Mercantile marine exempt persons, etc. 

Exchequer grants. 

Carriage of contribution cards to insurance commission, 

refunded by exchequer. 

Ministry of Pensions: Grants toward cost of benefits of 

invalided seamen, marines, soldiers, and airmen. 

Ministry of Labor: Contributions under out-of-work 

donation scheme.. 

Interest on investments in securities selected by socie¬ 
ties, held by commissioners on behalf of societies (in¬ 
cluding income tax refunded). 

Capital sums paid by late entrants into insurance. 

Sums recovered from employers for credit of societies in 
proceedings under section 70ofnationalinsuranceact, 
1911. 


1917 


£134,949 

11,985,418 
41,796 
94,664 

945,568 
8,086 
5,929 

798 

621 

2,004.604 
18,721 
4,054,698 

36 


Other Government departments, etc., for sanatorium 
benefit provided to men in His.Majesty’s forces prior 

to discharge. 

Other Government departments, for refunds of benefits 
paid as advances to discharged seamen,_ marines, and 
soldiers under section 1 (2) of national insurance act, 
1915.. 


Other Government departments, for medical treatment 
provided to noninsured camp construction workers... 

Miscellaneous receipts. 

Forsale of investments on behalf of societies for reinvest¬ 
ment. 

Transfer from national health insurance fimd (Ireland).. 
National debt commissioners, withdrawal from tempor¬ 
ary investments. 


Total. 


70,172 
2,190 


5,332 

3,988 


108 

2,256 
12,907 


1918 


£422,426 

11,947,375 
34,706 
113,048 

926,351 
7,057 
4,431 

521 

212 

2,277,331 
16,317 
5,120,346 

89 

322,411 


19, 392,881 


126,051 

267 


32 
2,330 

8,238 

622 

158 

7,434 


1919 


£762,486 

12,407,780 
37,176 
107,937 

927,648 
592 
3,636 

2,176 

382 

1,047,313 
14,646 
5,967,943 

127 

207,000 

602,000 


234,121 
20 


21,337,753 


1,941 


615 

26 

285 

4, 789 


350,000 


22,680,639 


1920 


£3Gi, 110 

17,402,721 
38,604 
107,713 

1,276,080 


6,193 

416 

659 

309,717 
16,370 
6,957,592 

158 

175,000 


305,376 


524 


331 

30 

472 

100 


26,959,166 





















































OPERATIONS OP THE SYSTEM. 81 


ABSTRACT OF CASH PAYMENTS OF THE NATIONAL HEALTH INSURANCE FUND OF 
ENGLAND FOR THE YEARS 1917,1918, 1919, AND 1920. 

[Source: First annual report of the Ministry of Health, 1919-20. Part IV. Administration of national 
health insurance (1917 to March 31, 1920).' Page 79. Second annual report of the Ministry of Health, 
1920-21. Cmd. 1446. Page 209. £ at par = $4.8665.) 


Item. 


Societies for benefits and expenses of administration 
(including postal drafts paid and charges thereon).... 
Insurance committees for medical and sanatorium bene¬ 
fits and expenses of administration. 

War bonus allowances to medical practitioners. 

Deposit contribu ors, for benefits, etc. 

Navy and army insurance fimd, for benefits. 

Sanatorium benefits for discharged seamen, marines, 

soldiers, and airmen (suspense account). 

Refund of sanatorium benefits paid by other Govern¬ 
ment departments. 

Refund of maternity benefits paid by other G ovemment 

departments. 

Special grants toward cost^tmedical attendance of aged 

and disabled members offriendly societies. 

Stationery office charges for printing on behalf of socie¬ 
ties and insurance committees. 

Refunds on account of health insurance stamps returned 

to commissioners.. 

Refunds of contributions paid in error. 

Exchequer in respect of expenses of administration of 
navy and army insurance fund, exempt persons fimd, 
and approved societies (officers) guaranty fund (Eng¬ 
land). 

Board of education, for amounts payable under section 

52 of national insurance act, 1911. 

Ministry of Labor, health insurance stamps affixed to 

unemployment insurance books. 

Inland revenue, health insurance stamps affixed to in¬ 
come tax cards. 

Contributions to approved societies (officers) guaranty 

fund (joint committee). 

Societies for losses by defalcations made good out of 
approvedisocieties (officers) guarantee fund (England). 

Miscellaneous payments. 

Societies for investment: 

Issues to societies. 

Issues to societies on behalf of national health insur¬ 
ance funds, other countries. 

Purchases on behalf of societies of securities selected by 

societies. 

National debt commissioners for temporary investment . 
National debt commissioners for investment on behalf 
of approved societies (officers) guaranty fund (Eng¬ 
land). 

Payments to married women under section 22 (8) of 

national insurance act, 1918. 

Payments to special fund constituted under section 27 

of national insurance act, 1918. 

Transfers to national health insurance funds, other 

countries. 

Balance at end of year. 

Total. 


1917 

1918 

1919 

1920 

£6,750,320 

£7,315,955 

£8,035,254 

£10,264,344 

4,721,460 

5,472,410 

6,338,731 

10,116,617 



298,232 

52,849 

24,461 

28,410 

45,'025 

53,284 

35,270 

58,545 

82,540 

109,056 

2,675 

1,411 

3,239 

4,253 

368 




22,616 

15,545 

18,630 

9, 807 

8,038 

3,685 

2,964 

2,634 

84 

196 

250 

1,013 

2,636 

2,387 

3,701 

7,064 

68 

97 

69 

107 

11,413 

18/501 

31,687 

64,669 

649 

684 

1,322 


1,371 

966 

560 

473 

36 

73 

97 

111 

11,589 

6,102 

6,022 

6,788 

346 

107 

114 

6 

124 

8 

3 

116 

2,358,647 

4,362,969 

5,314,279 

3,048,465 

14,287 



1,799 

1,137,497 

1,447,216 

2,134,310 

1,068,979 

3,860,000 

1,840,000 


850,000 

6,500 


2,500 

4,500 




20,290 




125,500 




97,154 

422, 426 

762,486 

361,110 

936,188 

19,392, 881 

21,337,753 

22,680,639 

26,559,166 


MINISTRY OF HEALTH. 

The appropriations for the health insurance system will in the 
future be expended principally by the Ministry of Health for England 
and Wales, the Scottish Board of Health, and the Irish insurance 
commissioners. The figures for the Irish body are given in a form 
which does not correspond to those of the other bodies, and as the 
number of insured persons is not large the appropriations are not 
given here, to avoid complicating the statement. For the fiscal year 
ending March 31, 1921, the following amounts were appropriated to 
be disbursed by the ministry and the Scottish board for health 
insurance purposes. 
















































82 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


APPROPRIATIONS FOR NATIONAL HEALTH INSURANCE TO THE MINISTRY OF 
HEALTH AND TO THE SCOTTISH BOARD OF HEALTH FOR THE YEAR ENDING 
MAR. 31,1921. 


[Source: Estimates for civil services for the year ending March 31,1921. London, 1920. House of Com¬ 
mons Paper 2-VII of 1920. Pages 6, 7, and 20. £ at par =>.$4.8665.] 


Contributions,benefits, etc., under the nationaiinsurance(health)act, 

1911 to 1919. 

Ministry o 

England. 

f Health. 

Wales. 

Scottish 
Board of 
Health. 

Statutory contributions: 

Weekly contributions. 

£1,000 
1,208,000 
2,137,000 
527,000 

4,835,000 
184,800 
155,000 
45,000 
4,000 

£400 
72,000 
157,900 
32,200 

314,000 

11,500 

10,000 

5,000 

1,000 

£300 
162,500 
294,000 
71,300 

712,000 
19,000 
7,100 
7,500 
600 

Medical and sanatorium benefits (grants in aid). 

Sickness,disablement,and maternity benefits (grants in aid). 
Expenses of administration, societies, and committees (grants in aid) 
Special grants: 

Medical benefit (grants in aid). 

Administration of medical benefit, etc. (grants in aid)_ 

Medical referee—consultants, etc. 

Sanatorium benefit. 

Expenses of members of insurance committees.... 


The above statement does not include the office of the minister of 
health nor the office of the Scottish secretary, which acts as the 
central authority over the insurance departments as well as over the 
other divisions of these two bodies. A relatively small amount for 
the printing, etc., of insurance stamps is also not included. 

The items under “ statutory contributions” are the two-ninths of 
expenditure for benefits, administration, etc., required by the law. 
Under the 11 special grants,’ 7 the payments for medical benefit, includ¬ 
ing doctors’ fees, make up the principal amount. 

STAFF OF INSURANCE DEPARTMENT. 

The number of persons on the staff of the insurance department of 
the ministry and the scale of salaries provided shows the organization 
of a staff to supervise the administration of the system, but it does 
not include the staff of the immediate office of the minister. 


ORGANIZATION OF STAFF OF INSURANCE DEPARTMENT, MINISTRY OF HEALTH 

1920-21. 


[Source: Estimates for civil services for the year ending Mar. 31,1921, London, 1920 

Papers 2-VII of 1920. Page 10. £ at par=$4.S665.] 


Occupation. 


Controller. 

Deputy controller. 

Assistant secretary.* 

Heads of branches.. 

Superintending clerks.[. ’ ’. 

First-class clerks.’ ” 

Second-class clerks. ’**“** 

Superintendent of index clearance. 

Staff clerk. 

Chief inspector. 

Chief inspector (woman). 

D ivisional inspectors. 

Allowance to one for acting as deputy chief inspector. 

Inspectors. 

Inspectors (woman).*’ " ’ 

Assistant inspectors. 

Assistant inspectors (woman). 

Health insurance officers.’ ’' 

Health insurance officers (woman). 


Minimum 

salary. 

Annual 

increase. 

Maxi¬ 

mum 

salary. 

£1,200 

£50 

£1,500 

1,000 

50 

1,200 

850 

50 

1,000 

850 

25 

1,000 

550 

20 

700 

350 

15 

500 

100 

0) 

350 

2 600 


2 600 

300 

15 

400 

2 1,000 


2 1,000 

400 

20 

550 

550 

20 

700 

2 100 


2 100 

350 

15 

500 

300 

15 

400 

100 

0) 

350 

100 

10 

300 

80 

( 1 2 3 ) 

200 

80 

( s ) 

200 


House of Commons 


1920-21. 


Number 
on staff. 

Amount 
spent for 
salaries. 

1 

£1,388 

1 

1,038 

1 

1,000 

3 

2,594 

15 

8,635 

32 

12, 648 

67 

9,067 

1 

600 

1 

308 

1 

1,000 

1 

531 

10 

6,623 


100 

41 

18,082 

10 

3,990 

87 

16,054 

41 

6,757 

93 

14, 657 

10 

1,454 


1 Increase of £20 at end of first two years’ service, then £10 per year up to £200, and then £15 per vear 

up to maximum. ’ ± 

2 Flat amount. 

s £5 per year up to £110 then £7 10s. up to £150, and then £10 up to maximum. 









































































OPERATIONS OF THE SYSTEM. 


83 


Under the civil-service system a position is allotted a basic salary, 
which is increased by certain increments for periods of service, 
ihe office is a large one, as there is a mass of detail to be handled. 

NATIONAL HEALTH INSURANCE JOINT COMMITTEE. 

The scope of the work of the National Health Insurance Joint 
Committee has been changed in many respects by the ministry of 
health act of 1919 and by the new regulations issued under that 

act ; a PP ro priations for this committee since 1912 have been 

as follows: 


APPROPRIATIONS FOR THE NATIONAL 
FOR FISCAL YEARS 


HEALTH INSURANCE JOINT COMMITTEE, 
ENDING 1913 TO 1921. 


[Source: Estimates for civil services, 1914-1921.] 


Object of appropriation. 

1912-13 

1913-14 

1914-15 

1915-16 

1916-17 

1917-18 

1918-19 

1919-20 

1920-21 

Salaries and allowances. 

Special inquiries and services. 

Traveling and incidental expenses 
Insurance stamps, benefits, etc... 
Special drug fund (Great Britain). 

£ 

24,020 

2.500 
2,550 

8.500 

£ 

14,127 
500 
1,250 
6,000 
30,000 

50,000 

82,700 

£ 

16,964 

1,250 

750 

5,000 

30,000 

54,000 

116,000 

56,500 

30,000 

80,000 

500,000 

50,000 

50,000 

100,000 

100,000 

£ 

15,575 

750 

1,000 

5,600 

30,000 

13.500 

40,350 

56.500 
30,000 

100,000 

150,000 

50,000 

25,000 

50,000 

50,000 

£ 

13,059 

750 

1,000 

5,600 

100 

37,000 

59,000 

50,500 

6,500 

100 

100 

£ 

12,846 

750 

750 

5,900 

£ 

12,998 

750 

750 

5,900 

£ 

1,750 

300 

£ . 
2,280 

50 

Mileage (Great Britain, excluding 
parts of Scotland). 


55,000 

95,000 

50,000 

4,400 

100 

10,000 

74,000 

94,000 

54,600 

3,800 



Administration of medical benefit, 
etc. 




Medical research fund. 




Expenses of insurance committee 
Arrears o f contributions.. . 





Sickness benefit (women)... 
Medical reference consultants, etc. 
(Great Britain). 



1225,000 

1250,000 

>250,000 

Supplementary medical service 
(Great Britain). 








Nursing grants. 








Sanatorium benefit. 



35,000 

35,000 

75,000 



Insurance committee (United 
Kingdom). 


22,650 



Medical attendance, etc., of aged 
and disabled members. 


28,000 







Centralfund. 






150,000 

150,000 

150,000 

4Fotal. 







37,570 

207,227 

1,218,964j 

618,275 

208,709 269,746: 696,798 

402,050 

402,330 


1 Women’s equalization fund. 


The larger appropriations for 1914-15 were due first to a grant 
of £500,000 ($2,433,250, par) for pregnancy benefit for the approved 
societies, which was later turned over to the women’s equalization 
fund, and second to a grant of £100,000 ($48^,650, par) for provid¬ 
ing, on a national scale, a system of visiting nurses in connection 
with medical benefit. The latter appropriation was returned to 
the treasury because war conditions made it impossible to secure 
the nurses, and action on the project has been deferred. The total 
appropriations for the two years 1919-1921 are slightly in excess of 
£400,000 ($1,946,600, par) annually. Beginning with 1920-21, 

many of the accounts will be carried under the appropriations for 
the Ministry of Health, the Scottish Board of Health, and the Irish 
Insurance Commissioners. 




















































84 NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


RECEIPTS AND EXPENDITURES OF APPROVED SOCIETIES. 

The operations of the approved societies as regards their receipts 
and expenditures down to the end of the year 1916 have been as 
follows: 


RECEIPTS AND PAYMENTS OF APPROVED SOCIETIES, JULY 15. 1912, TO DECEMBER 31, 
1916, UNDER SECTION 54 (1) 1 2 OF THE NATIONAL INSURANCE ACT, 1911. 


[Source: National health insurance fund accounts. Appendix. Approved societies and insurance com¬ 
mittees’ receipts and payments: July 15, 1912, to Dec. 31, 1914. London, 1919. Cmd. 212. Page 2, 
1915 and 1916. Cmd. 691. Page 2. As each item is given to the nearest pound, the totals do not exactly 
balance. £ at par=$4.8665.] 


JULY 15, 1912, TO JANUARY 11, 1914. 


Item. 

Friendly 

societies 

with 

branches. 

Friendly 

societies 

without 

branches. 

Industrial 

and 

collecting 

societies. 

Trade 

unions. 

Employ¬ 

ers’ 

funds. 

Total. 

RECEIPTS. 

From national health insurance 
fund: 

England. 

£2,292,065 

£1,851,885 

322 

823 

212,188 

£3,593,654 

£956,606 

£80,699 

£8,774,909 
322 
13,702 
334,825 

Other cash receipts. 

Balance owing to societies. 

Total. 

3,412 
20,358 

8,466 
14,836 

962 

84,590 

39 

2,852 

2,315,834 

2,065,219 

3,616,956 

1,042,158 

83,590 

9,123,758 

PAYMENTS. 

Benefits (net): 

Sickness, men. 

Sickness, women. 

Maternity, men. 

Maternity, women. 

913,580 
222,008 
231,386 
3,822 

809,242 

287.366 

233.367 
4,213 
4,531 

924 

4,360 

1,058,636 
1,067,138 
347,517 
21,265 

472,685 
120,495 
133,304 
1,262 

37,030 
10,512 
12,020 
93 

3,291,174 
1,707,520 
957, 594 
30,655 
4,531 
924 
6,702 






Other charges to benefit fund. 

Total benefits. 

Administration (net). 

Balances in hands of societies. 

Total. 

290 

1,053 

• 954 

44 

1,371,087 

2 571,198 
373,550 

1,344,003 
600,550 
120,665 

2,495,609 
852,324 
269,024 

728, 701 
262,241 
51,217 

59,701 
19,694 
4,194 

5,999,101 
2, 306,007 
818,650 

2,315,834 

2,065,219 

3,616,956 

1,042,158 

83,590 

9,123,758 

• 


JANUARY 12, 1914, TO DECEMBER 31, 1914. 


RECEIPTS. 

From national health insurance 
fund: 

England. 

Rpnt.lG.nrl jfr 

£1,863,092 

26 

£1,826,049 

£3,562,346 

£957,142 

£72,896 

£8,281,524 

26 

6 

37,142 

818,650 

294,454 

Wales 

6 

7,870 
121,387 
187,551 




Other cash receipts. 

Balances Jan. 11, 1914. 

Balances owing to societies. 

Total. 

3,819 
372,828 
24, S90 

23,156 

269,024 

13,066 

2,095 

51,217 

65,109 

202 
4,194 
3,838 

2,264,655 

2,142,864 

3,867,591 

1,075,562 

81,131 

9,431,802 


1 Act of 1911, section 54.—(1) All sums received in respect of contributions under this part of this act 
and all sums paid out of moneys provided by Parliament under this part of this act in respect of the benefits 
thereunder and the expenses-of administration of such benefits shall be paid into a fund, to be called the 
national health insurance fund, under the control and management of the insurance commissioners, and 
the sums required to meet expenditure properly incurred by approved societies and insurance committees 
for the purposes of the benefits administered by them and the administration of such benefits shall be paid 
out of that fund. 

2 This amount includes payments charged in the administration accounts of branches in respect of levies 
for the purpose of meeting the administration expenses of head office and districts. The sum of £7,835 
10s. 8d. remained in the hands of head office and districts not expended Jan. 11, 1914. 



























































Operations of the system 


85 


RECEIPTS AND PAYMENTS OF APPROVED SOCIETIES, ETC.—Continued. 

JANUARY 12, 1914, TO DECEMBER 31, 1914— Concluded. 


Item. 

Friendly 

societies 

with 

branches. 

Friendly 

societies 

without 

branches. 

Industrial 

and 

collecting 

societies. 

Trade 

unions. 

Employ¬ 

ers’ 

funds. 

Total. 

PAYMENTS. 

Benefits (net): 

Sickness, men. 

Sickness, w omen. 

Disablement, men. 

Disablement, women. 

Maternity, men. 

Maternity, women. 

AT ptJ i pal 

£974,419 
236,103 
43,090 
7,317 
200,700 
16,927 

£865,546 
282,671 
29,294 
8,623 
230,529 
19,188 
11,107 
2,641 
7,989 

£1,270,283 
1,044,012 
26,270 
17,175 
355,076. 
123,461 

£513,908 

94,611 

14,749 

1,829 

132,704 

12,678 

£39,640 

8,992 

1,431 

337 

11,413 

640 

£3,663,796 

1,666,388 

114,835 

35,281 

930,423 

172,894 

11,107 

2,641 

17,030 

Ran atnri 11 m 





Other charges to benefit fund. 

Total benefits. 

Administration (net). 

National health insurance 

fund (Scotland). 

Balances Jan. 11, 1914. 

Balances in hands of societies. 

Total. 

1,348 

6,936 

572 

185 

1,479,904 

3 386,581 

25 

20,344 

377,800 

1,457,586 

395,977 

19 

212,202 

77,079 

2,843,212 

626,829 

14,836 

382,714 

771,052 

179,309 

817 

84,590 

39,793 

62,639 
12,132 

2,852 

3,508 

6,614,393 

1,600,829 

861 
334,825 
880,894 

2,264,655 

2,142,864 

3,867,591 

1,075,562 

81,131 

9,431,802 


a This amount includes payments charged in the administration accounts of branches in respect of levies 
for the purpose of meeting the administration expenses of head office and districts. The sum of £10,920 
7s. 9d. remained in the hands of head office and districts not expended Dec. 31,1914. 


YEAR ENDING DECEMBER 31, 1915. 


RECEIPTS. 

From national health insurance 
fund: 

England. 

£1,796,898 

41 

17 

10,804 

377,778 

16,340 

£1,879,632 

2 
22 
19,934 
77,101 

83,384 

£2,989,495 

£879,158 

£76,162 

£7,621,345 
43 
68 
70,040 
880,894 

161,541 

"IVaIps 

29 

3,431 

39,793 

51,980 


Other cash receipts. 

Balances Dec. 31,1914..... 

Balances owing to societies Dec. 
31, 1915. 

35,343 
382,714 

7,201 

528 

3,508 

2,636 

Total. 

PAYMENTS. 

Benefits (net): 

Sickness, men. 

Sickness, women..... 

Disablement, men. 

Disablement, women. 

Maternity, men. 

Maternity, women. 

2,201,877 

2,060,076 

3,414,754 

974,391 

82,834 

8,733,931 

848,430 
205,669 
152,388 
35,372 
193,442 
16,091 

716,133 
245,332 
115,370 
43,513 
216,137 
18,134 
9,792 
3,130 
9,829 

875,829 
802,410 
135,621 
111,531 
329,500 
109,483 

398,824 
77,038 
63,691 
10,170 
121,810 
10,708 

35,025 

8,577 

5,306 

1,563 

10,674 

589 

2,874,241 

1,339,026 

472,376 

202,153 

871,565 

155,005 

9,792 

3,130 

25,948 






Other charges to benefit fund 

Total benefits. 

Administration (net). 

National health insurance 
fund: 

2,612 

10,876 

2,346 

285 

1,454,008 

4 405,572 

1,377,370 
413,125 

6 

2,375,251 

786,813 

684,588 
178,861 

3,356 

6 

384 

65,109 

41,988 

62,019 

12,242 

5,953,236 

1,796,713 

3,362 

7 

388 

294,454 

785,772 




1 

1 

3,840 

4,731 



3 

187,567 

82,004 


Balances Dec. 31,1914. 

Balances in hands of societies. 

Total. 

24,872 

317,425 

13,066 

239,623 

2,201,877 

2,060,076 

3,414,754 

974,391 

82,834 

8,733,931 


4 This amount includes payments charged in the administration accounts of branches in respect of levies 

,or ^ prapo™ of m“ttag the administration expenses of head offlce and districts The sum of £12,903 
8s. Hid. remained in the hands of head office and districts not expended Dec. 31, 191o. 






























































































86 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN 


RECEIPTS AND PAYMENTS OF APPROVED SOCIETIES, ETC—Concluded. 

YEAR ENDING DECEMBER 31, 1916. 


Item. 

Friendly 

societies 

with 

branches. 

Friendly 

societies 

without 

branches. 

Industrial 

and 

collecting 

societies. 

Trade 

unions. 

Employ¬ 

ers' 

funds. 

Total. 

RECEIPTS. 

From national health insurance 
fund: 

England. 

Scotland. 

£1,613,159 

£1,614,898 

£2,926,056 

£805,165 
30 
3 
35 
4,624 
41,988 
57,990 

£65,053 

£7,024,332 

30 

3 

37 

120,683 
685,772 
169,942 

Ireland. 





Wales. 


2 

32,892 
82,398 
91,445 



Other cash receipts. 

Balances Dec. 31,1915. 

Balances owing to societies. 

Total. 

PAYMENTS. 

Benefits (net): 

Sickness, men. 

Sickness, women. 

Disablement, men. 

Disablement, women. 

Maternity, men. 

Maternity, women. 

Medical. 

22,457 

317,031 

15,660 

60,039 

239,623 

2,264 

672 

4,731 

2,582 

1,968,307 

1,821,636 

3,227,982 

909,835 

73,038 

8 ,000,799 

698,449 
178,203 
183,200 
48,900 
186,439 
16,523 

602,041 
212,631 
145,036 
62,061 
208,456 
18,471 
7,904 
3,112 
14,602 

767,447 
665,686 
182,749 
168,097 
308,211 
102,308 

351,404 
66,663 
82,598 
15,269 
117,573 
9,428 

29,366 
7,403 
6,428 
1,981 
9,699 
562 

2,448,707 
1,130,585 
600,011 
296,309 
830,379 
147,293 
7,904 
3,112 
35,596 

Sanatorium. 





Other charges to benefit fund. 

Total benefits. 

Administration (net). 

National health insurance 
fund— 

Scotland. 

3,433 

14,312 

2,836 

414 

1,315,146 

5 389,579 

1,274,316 

403,476 

16 

3,703 

83,388 

56,736 

2,208,810 
790,252 

645,772 
175,704 

55,853 

12,447 

5,499,896 
1,771,457 

16 
3,703 
161,541 
564,185 

Wales. 





Balances Dec. 31,1915. 

Balances in hands of societies. 

Total. 

16,335 

247,246 

7.201 
221,719 

51,980 
36,380 

2,636 

2,103 

1,968,307 

1,821,636 

3,227,982 

909,835 

73,038 

8 ,000,799 


& This amount includes payments charged in the administration accounts of branches in respect of levies 
for the purpose of meeting the administration expenses of head office and districts. The sum of £14 689 
13s. 6^d. remained in the hands of head office and districts not expended Dec. 31, 1918. 


For the years 1917 to 1920 the annual reports of the Ministry of 
Health (Cmd. 913 and 1446) present the figures in a slightly different 
form, so no attempt has been made to combine them with the pre¬ 
ceding table. The statement is as follows: 


APPROXIMATE RECEIPTS AND PAYMENTS OF APPROVED SOCIETIES (ENGLAND) 

1917, 1918, 1919, AND 1920. 


[Source: First annual report of the Ministry of Health, 1919-20. Part IV. Administration of national 
health insurance (1917 to Mar. 31, 1920). Page 77 Second annual report of the Ministry of Health 
1920-21. Cmd. 1446. Page 207. £ at par =$4.8665], * 


Item. 


RECEIPTS. 

From national health insurance fund (England).... 

Other receipts..... 

Balances (net) brought forward Jan. 1. 

Total. 

PAYMENTS. 

Benefits (net): 

Sickness, men. 

Sickness, women.] 

Sickness, women, Class K. 

Disablement, men. 

Disablement, women. 

Maternity, men. 

Maternity, women. 

Maternity, women, Class K. 

Other benefit fund charges, including married 
women's credits. 

Total benefits. 

Administration (net). 

Balance (net), Dec. 31. 

Total. 


1917 

1918 

1919 

1920 

£6,750,320 
292,728 
394,243 

£7,315,955 
459,631 
438,053 

£8,035,254 
683,026 
449,272 

£10,264,000 
868,000 
617,000 

7,437,291 

8,213,639 

9,167,552 

11,749,000 

2,277,815 
1,119,040 

2,610,150 
1,388,080 
780 
665,625 
377,070 
637,550 
150,975 
2,460 

87,175 

2,806,350 
1,264,500 
5,960 
699,640 
411, 560 
710,100 
161,940 
49,450 

331,040 

3,356,000 

1,598,000 

15,000 

994.500 

596.500 
1,159, 000 

230. 000 
151,000 

61,000 

644,560 
340, 585 
680,400 
140,285 

45,000 

5,247, 685 
1,751,553 
438,053 

5,919,865 
1,.844,502 
449,272 

6,440, 540 
2,110,286 
616,726 

8,161,000 
2,633,000 
955,000 

7,437,291 

8,213,639 

9,167,552 

11,749,000 










































































































OPERATIONS OF THE SYSTEM. 


87 


RECEIPTS AND EXPENDITURES OF INSURANCE COMMITTEES. 

Thefollowing table shows the financial operations of the insurance 
committees in their administration of the medical and sanatorium 
benefits down to the end of the year 1916. 

RECEIPTS AND PAYMENTS OF INSURANCE COMMITTEES, 1912 TO 1916, UNDER 
SECTION 54 (1) i OF THE NATIONAL INSURANCE ACT, 1911. 

[Source: National health insurance fund accounts. Appendix. Approved societies and insurance com¬ 
mittees’ receipts and payments, July 15,1912, to December, 31,1916. London, 1919. Cmd. 212. Page 6. 
1915-196, Cmd. 691. Page 6. As each item is given to the nearest pound, the totals do not exactly bal¬ 
ance. £ at par=$4.8665.) 


Item. 

From July 
15,1912, to 
Jan. 11,1914. 

From Jan. 
12,1914,to 
Dec. 31,1914. 

Year 1915. 

Year 1916. 

RECEIPTS. 

From commissioners for medical and sanatorium 

benefits and expenses of administration. 

Other receipts: 

For benefits of deposit contributors. 

From approved societies. 

Interest. 

£4,622,343 

288 

7,501 

6,494 

5 

£5,377,462 

438 

15,657 

7,969 

7 

661,980 

£4,501,524 

510 

18,101 

6,619 

54 

444,061 

£4,975,530 

677 

18,431 

6,721 

42 

332,511 

Sundries. 

Balances brought forward. 

Total. 


4,636,631 

6,063,511 

4,970,869 

5,333,911 

PAYMENTS. 

Medical benefit (including temporary residents) U.. 
Mileage. 

3,371,800 

1,928 

339,146 

260,855 

287 

635 

661,980 

4,855,206 
19,583 
440,136 
301,956 

429 
2,142 
444,061 

3,971,809 

18,072 

403,300 

241,948 

490 

2,740 

332,511 

4,354,037 
19,845 
330,078 
235,068 

703 
% 2,335 
301,846 

Sanatorium benefit 2 . 

A dministration 3 . 

Other payments: 

Benefits of deposit contributors. 

Sundries. 

Balances in hands of insurance committees. 

Total. 

4,636,631 

6,063,513 

4,970,869 

5,333,911 



1 See note (a) to table on page 75. 

2 The payments shown for medical benefit include payments to practitioners in respect of the domiciliary 
treatment of persons suffering from tuberculosis. The sums payable under this heading in respect to the 
above neriods were as follows: Period from July 15,1912, to Jan. 11,1914, £263,207 7s. 3d.; period from Jan. 
12,1914, to Dec. 31,1914, £249,278 15s. 7d.; year 1915, £237,090 19s. 5d.; year 1916 £224,927 Us. 7d. 

3 The payments shown for administration include the proportion of the expenses of administration 
attributable to sanatorium benefit. 

For the three-year period 1917-to 1920, the receipts and payments 
are given in the Ministry of Health reports as follows: 

APPROXIMATE RECEIPTS AND PAYMENTS OF INSURANCE COMMITTEES (ENGLAND) 

1917, 1918, 1919, AND 1920. 


[Source: First annual report of the Ministry of Health, 1919-20. Part IV. Administration of national 
health insurance (1917 to March 31, 1920.) Page 77. Second annual report of the Ministry of Health, 
1920-21. Cmd. 1446. Page 207. £ at par=$4.8o65.1 



Item. 

1917 

1918 

1919 

1920 

RECEIPTS. 

From national health insurance fund (England) — 
Other receipts. 

£4,721,460 

27,965 

391,846 

£5,472,410 
39,116 
400,937 

£6,338,731 
30,590 
404,643 

£10,117,000 

22,000 

520.000 

Balances brought forward Jan. 1. 

Total. 

5,141,271 

5,912,463 

6,773,964 

10,659,000 

PAYMENTS. 

Medical benefit. 

4,092,164 
30,682 
361,113 
225,789 
30,586 

4,774,963 
42,427 
403,191 
261,204 
26,035 

5,036,969 
40,205 
563,440 
341,985 
9,668 
261,469 
520,198 

7,889,000 

128,000 

839,000 

437,000 

9,000 

302,000 

1,055,000 

Mileage. 

Sanatorium benefit.•.. 

A d ministration.. 

Other payments. 

Wat a 11 fiwan pas t.n rl nrtnrs . 

Balances Dec. 31. 

400,937 

404,643 

Total. 

5,141,271 

5,912,463 

6,773,964 

10,659,000 




































































88 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


Throughout the period referred to in the preceding tables, the 
amounts received and paid out have fluctuated only within narrow 
limits. Attention should be called, however, to items under expendi¬ 
ture of the National Health Insurance Joint Committee and the 
Ministry of Health, where the special grants provided for medical 
service are listed. 

STATISTICS OF SICKNESS. 

The British insurance system had barely gotten a fair start when 
the war made necessary a drastic reduction in expenditure of money 
and of man power for social-welfare purposes. One of the subjects 
which was immediately held in abeyance was the collection of all 
statistical data. For this reason there is very little published infor¬ 
mation as to sickness rates, death rates, etc., of the insured popula¬ 
tion in connection with the insurance system. 

The following tables are reproduced from the reports of the 
chief medical officer of the Ministry of Health. 

Causes of death .—The relative importance of the causes of death 
among the English population as a whole during 1921 is shown in 
the following table: 


CAUSES OF DEATH IN ENGLAND AND WALES, 1921. 

[Source: Annual report of the chief medical officer of the Ministry of Health for the year 1921. London 

1922. Page 13.] 


Cause of death. 

Number of 
deaths 

Proportion 
per 1,000 
deaths from 
all causes. 

Measles. 

2 241 

n 

Whooping cough. 

4*576 

o 

10 

Diphtheria. 

4* 772 

in 

Influenza. 

8*995 

1 U 

90 

Tuberculosis of respiratory system. 

33*505 

9 173 

73 

90 

Other forms of tuberculosis. 

Cancer. 

46*022 

inn 

Diseases of nervous system and sense organs. 

48*217 
53 707 

ins 

Disease of the heart. 

1 UO 

117 

Other diseases of circulatory system. 

14*571 

11 I 

19 

Bronchitis. 

33*684 


Pneumonia. 

34* 708 

#o 

7 a 

Other diseases of respiratory system. 

5*707 

/O 

19 

Diarrhea and enteritis. 

17*086 

17 

Other diseases of digestive system. 

18*329 

o# 

40 

Diseases of genito-urinary svstem. 

17*862 

*±u 

IQ 

Premature birth and diseases of early infancy. 

26*442 
27 406 

0*7 

so 

Old age.I.. . 

Oo 

AO 

Violence (all forms). 

16*501 

35,125 

OU 

oa 

Other causes. 

oO 

77 


4 4 

Total. 

4 AQ AOQ 

1,000 

. 

'XtJOy \JA\7 


The principal causes of death in 1921 were about the same as in the 
preceding years. Diseases of the heart, diseases of the nervous sys¬ 
tem, and cancer caused nearly one-third of the total deaths, while 
pneumonia, bronchitis, and tuberculosis caused nearly one-fourth. 

To show the nature of the sickness which causes the serious loss of 
working power to the insured population, referred to elsewhere, the 
chief medical officer prepared two statements of-proportionate mor¬ 
bidity in representative areas; the first statement, for 1916, included 
about 5,000 cases, while the second, for 1921, included about 36,000 
cases. The cases were taken from the records of representative insur¬ 
ance practitioners in various cities. The data are as follows: 




































OPERATIONS uP THE SYSTEM. 89 

PROPORTION OF CERTAIN DISEASES AMONG INSURED PERSONS IN REPRESENTA¬ 
TIVE CITIES, 1916 AND 1921. 

[Source: Annual report of the chief medical officer of the Ministry of Health for the year 1920, page 39: 

for the year 1921, page 28.] 


Disease. 

1916, both sexes. 

1921 

Both sexes. 

Males. 

Females. 

Num¬ 
ber of 
cases. 

Pro¬ 

por¬ 

tion 

per 

1,000 

cases. 

Num¬ 
ber of 
cases. 

Pro¬ 

por¬ 

tion 

per 

1,000 

cases. 

Num¬ 
ber of 
cases. 

Pro¬ 

por¬ 

tion 

per 

1,000 

cases. 

Num¬ 
ber of 
cases. 

Pro¬ 

por¬ 

tion 

per 

1,000 

cases. 

Influenza. 

Tuberculosis, all forms. 

Organic heart disease. 

Anemia. 

Bronchitis, bronchial and nasal 

catarrh, cold, etc. 

Pneumonia and other diseases of 

the respiratory system. 

Diseases of digestive system. 

Diseases of genito-urinary system_ 

Diseases of nervous system and 

special senses. 

Skin diseases. 

Injuries and accidents. 

Abscess, boils, and other septic con¬ 
ditions . 

Lumbago, rheumatism, etc. 

Debility, neuralgia, and headache... 

Malignant disease 1 . 

Other diseases. 

Total. 

386 

62 

112 

202 

920 

351 

726 

144 

340 

239 

308 

249 

336 

285 

414 

76.1 

12.2 
22.1 
39.8 

181.3 

69.2 
143.1 

28.4 

67.0 

47.1 
60.7 

49.1 

66.3 
56.0 

81.6 

3,097 
505 
520 
1,157 

7,739 

537 

4,766 

912 

1,775 
1,741 
2,871 

2,503 

3,181 

1,999 

66 

2,956 

85.3 

13.9 

14.3 

31.9 

213.0 

14.8 
131.2 

25.1 

48.9 

47.9 
79.0 

68.9 
87.6 
55.0 

1.8 

81.4 

2,004 

320 

355 

74 

4,988 

395 

2,797 

339 

1,088 

1,039 

2,358 

1,647 

2,201 

855 

45 

1,720 

90.2 

14.4 
16.0 

3.3 

224.4 

17.8 

125.8 

15.3 

49.0 

46.7 

106.1 

74.1 

99.0 

38.5 
2.0 

77.4 

1,093 

185 

165 

1,083 

2,751 

142 

1,969 

573 

687 

702 

513 

856 
980 
1,144 
21 
1,236 

77.5 

13.1 

11.7 

76.8 

195.2 

10.1 
139.6 

40.6 

48.7 

49.8 

36.4 

60.7 

69.5 
81.1 

1.5 

87.7 

5,074 

1,000.0 

36,325 

1,000.0 

22,225 

1,000.0 

14,100 

1,000.0 


1 Not given separately for 1916. 


From the table it will be noted that the serious diseases, such as 
tuberculosis, malignant disease, and Organic heart disease, are rela¬ 
tively few in number, though they are conspicuous in the mortality 
tables. Such diseases as bronchitis and disorders of the digestive 
tract are prominent as causes of disability and prevent the insured 
population from following their usual occupations, though these 
diseases do not form so large a percentage as causes of death. 

OPERATIONS OF TYPICAL INDIVIDUAL CARRIERS. 

FRIENDLY SOCIETIES. 

Review of the year 1919 .—The attitude of the great friendly orders 
to the insurance system is always of importance, as they are the car¬ 
riers for the largest proportion of the insured persons. The follow¬ 
ing comment on the experience of these societies in 1919 is repro¬ 
duced from an insurance journal. 6 

The year 1919 has been one of reconstruction for British friendly societies. The 
war brought heavy claims upon their funds, and the fall in membership resulting 
from the deaths of many thousands of members on active service was intensified by 
the reluctance to accept young men of military age, other than those who came from 
the juvenile branches, because of the heavy liability involved. Many of the socie¬ 
ties suspended the payment of sickness benefit to members on active service, retaining 
them as members and paying the funeral claim in the event of death. The Man¬ 
chester Unity of Odd Fellows gave its service members the option of paying their own 


«The National Insurance Gazette, London, Saturday, Jan. 17,1920, p. 34. 






































90 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


contributions and receiving their full benefits or leaving the contributions unpaid and 
receiving only death payments, in which event the members at home paid 50 per cent 
of the contributions to provide the necessary reserves. A considerable percentage 
of the service members elected to pay their own contributions, and in the result the 
claims for sickness and disablement from wounds, though above the average, amounted 
to less than the general expectation. 

Most of the societies are considering various forms of memorials of members who 
served in the Great War. Some have already their war memorials in existence. The 
Manchester Unity of Odd Fellows, who received £438,357 [$2,133,264, par] on account 
of contributions of members serving in the forces, has inaugurated an orphan fund 
as a permanent war memorial. The voluntary gifts to this fund now exceed £6,800 
[$33,092, par], and the annual income from levy reaches £3,500 [$17,033, par]. The 
beneficiaries receive from birth to 5 years old 5s. [$1.22, par] per week; from 5 to 7, 6s. 
[$1.46, par]; from 7 to 9, 7s. [$1.70, par]; from 9 to 11, 8s. [$1.95, par]; from 11 to 13, 
10s. [$2.43, par], and from 13 to 16,12s. 6d. [$3.04, par] per week. The Ancient Order 
of Foresters has also decided upon a fund for widows and orphans, and the Hearts of 
Oak Benefit Society will establish a permanent memorial. 

Reconstruction schemes .—The societies are finding it necessary to consider recon¬ 
struction schemes to adapt their contributions and benefits to the changed circum¬ 
stances produced by the war. The rise in wages and the cost of living are giving 
renewed opportunities to the friendly societies, as many insured persons are now 
realizing the need for additional insurance in time of sickness. This is encouraging the 
societies to devise new and attractive benefit proposals. The Manchester Unity of 
Odd Fellows has decided that all members joining the society * * * must sub¬ 
scribe for an annuity benefit payable at 70 years of age, when the sickness benefit will 
cease. The Ancient Order of Foresters has decided upon new tables for future mem¬ 
bers, providing for the payment of sickness benefits up to 70, when contributions will 
cease, with the option of contributing for an annuity benefit from 70 onward. It has 
also decided to set up a contingency fund, which will be at the call of every court in 
the order according to its need. 

The aggregate membership of British friendly societies is about 7,000,000; the reserve 
funds to meet future liabilities total £60,000,000 [$291,990,000, par]; the annual income 
is about £8,000,000 [$38,932,000, par]; and the payments are about £6,000,000 
[$29,199,000, par]. These figures show how great a work the voluntary friendly socie¬ 
ties are doing, even against the competition of a compulsory insurance scheme, and 
how considerable a part they still play in the social life of the workers. 

The following are particulars of the principal societies: 

The Manchester Unity of Odd Fellows holds pride of place and is the only friendly 
society with a subscribing membership exceeding 1,000,000. The aggregate inde¬ 
pendent membership is 1,058,155, and the State section has a membership of 971,668. 
During the war period the deaths of members increased from 10,777 in 1913 to 20,529 
in 1918. The funds of the society amount to £17,972,990 [$87,465,556, par]. The 
annual income is £2,332,683 [$11,352,002, par], and payments £1,970,808 [$9,590,937, 
par]. 

The Ancient Order of Foresters has an independent membership of 981,674 and a 
State insured membership of 721,767. The reserve capital amounts to £11,098,754 
[$54,012,086, par], and the order is looking forward to a period of prosperity under 
peace conditions. - The high court at Norwich in August last carried a complete recon¬ 
struction of the tables of contributions and benefits, and with the operation of the 
new contingencies fund there should result a considerable further strengthening of 
the financial reserves. 

The Hearts of Oak Benefit Society had an independent membership on November 
30 of 379,116 and a State membership of 471,026. The admissions from Whitsuntide to 
November 22 number 17,670. For the 11 months to November 30 the society admitted 
22,686 voluntary members and 16,795 State-insured members. The income for the 
11 months was £692,767 [$3,371,351], and the payments, £438,068 [$2,131,858, par]. 
The total capital on November 30 was £5,385,434 [$26,208,215, par]. The society had 
8,909 members killed or died on active sendee and paid in respect of them £188,251 
[$818,793, par]. 

The National Deposit Friendly Society, the jubilee of which was celebrated at 
Nottingham in May, continues to make considerable progress. From January to 
October 30 the society admitted 52,942 new members into the deposit section and 
25,941 into the State-insured section. The membership at the end of 1918 was 456,231 
and the funds £2,710,304 [$13,189,694, par.] The president has offered to give the 


OPERATIONS OF THE SYSTEM. 


91 


society a freehold site of about 3 acres, near Skegness, and to contribute to the cost of 
building a convalescent home as a jubilee war memorial, conditional on the members 
generally and generously contributing to the memorial. 

The Independent Order of Rechabites has a total membership of 799,476. This 
order has the distinction of the largest juvenile membership, numbering 403,519. 
It has also a State-insured membership of 427,882. The capital amounts to £3,464,- 
369 [$16,859,352, par]. 

Statistics of other societies are: 

Ashton Unity of Shepherds: Independent members, 214,000; State insured, 189, 
512; funds, £1,491,189 [$7,256,871, par]. 

Order of the Sons of Temperance: Independent members, 270,000; State insured, 
142,890. 

Rational Association: Members, 174,454; State insured 124,700; capital, £740,540 
[$3,603,838, par]. 

Grand United Order of Odd Fellows: Members, 502,656 (of whom 370,036 are in 
America); State insured, 95,072; funds, £2,107,498 [$10,256,139, par]. 

Order of Druids: Independent members, 108,700; State insured, 94,000; capital, 
£282,521 [$1,374,888, par]. 

United Ancient Order of Druids: Independent members, 2*13,777; State insured, 
69,057; funds, £1,470,302 [$7,155,225, par]. 

National Independent Order of Odd Fellows: Independent members, 120,525; 
State insured, 80,000; funds, £597,000 [$2,905,301, par]. 

National Order of Free Gardeners: Independent members, 50,513; State insured, 
67,268; funds, £273,938 [$1,333,119, par]. 

British Order of Free Gardeners: Independent members, 77,728; State insured, 
67,268; capital, £441,712 [$2,149,591, par].—The Daily Telegraph, from its society 
correspondent. 

ESTABLISHMENT FUND. 

One of the types of organization authorized to act as an approved 
society is the establishment fund or employers’ provident fund. An 
instance of this type is the following : 7 

South Metropolitan Gas Company’s Employees’ Provident Society. 

EXTRACTS FROM REPORT OF THE COMMITTEE OF MANAGEMENT AND ACCOUNTS FOR 
THE YEAR ENDING DECEMBER 31, 1918. 


The year which saw the suspension of hostilities in the Great War was probably 
the most severe in the experience of approved societies since the national health 
insurance scheme came into operation; and in this respect our own society formed no 
exception. . . .... 

Sickness was very heavy; and management, both in its financial and administra¬ 
tive aspects, more exacting. The constantly changing status of members from civilian 
to military—from military back again to civilian—was a growing source of complexity, 
affecting in many ways the transaction of the ordinary State business of the society. 

The insurance commission (now the Ministry of Health) did their best to simplify 
matters; but it is not unfair to say that the arrangements made by the Government 
were, perhaps unavoidably, inadequate. In these circumstances, the company 
made good the shortcomings of the State; and the directors, to whom thanks are due, 
will be gratified to know that our members deeply appreciate what is done on their 
behalf to carry out with good will the purposes which the approved society was in¬ 
tended to fulfill. 

State membership .—Membership of the society at the end of 1918 was 5,211 as 
compared with 5,381 in December, 1917, a decrease of 170. This reduction was due 
partly to the temporary and uncertain conditions of employment in the company 
during the war, and partly to the unusually high death roll during the year under 
report. 


i The National Insurance Gazette, London, Feb. 7,1920, p. 71. 




92 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


State benefits. —It will be remembered that serving soldiers and sailors are not en¬ 
titled to sickness or disablement benefit, but their wives retain the right to claim 
maternity benefit. An analysis of the society’s experience gives the following 
results: 


Year. 

Sickness benefit. 

Disablement benefit. 

Number 
of claims 
paid. 

Percent¬ 
age of 
total 
civilian 
member¬ 
ship. 

Total cost. 

Average 
cost per 
member 
per week. 

Claims 

paid. 

Amount paid. 

Average 
cost per 
member 
per 
week. 




£ s. d. 

d. 


£ s. d. 

d. 

1916. 

1,614 

43.30 

2,027 12 10 

2.51 

67 

306 17 10 

0.379 

1917. 

1,619 

44.46 

2,133 10 3 

2.70 

110 

390 7 6 

.494 

1918. 

2,093 

61.55 

2,852 8 1 

3.87 

142 

494 2 6 

.670 


A return is also appended showing the annual sickness records of the society since 
the year 1901, from which it appears that the average length of sickness in days per 
member was 14.54 in 1918, as against 10.17 for 1917, an increase of 4.37 days. It will 
be seen that the amount of sickness during 1918 was higher than in any previous 
year. This result is not peculiar to our own society. It is attributable entirely to 
the serious influenza epidemic which swept over the country toward the end of 1918. 
with most deplorable consequences. Of the total sickness claims in our own society, 
influenza alone accounted for as many as 40 per cent, as against 15 per cent in the 
previous year, whilst the aggregate period of sickness produced amounted to 12,482 
days in 1918, as against 3,379 in 1917; and the charge on the State funds alone was 
£993 [$4,832.43, par], as compared with £256 [$1,245.82, par] in the preceding year. 

Another matter which the committee view with some anxiety is the increase in 
the number of cases of pulmonary tuberculosis. As against 10 cases in 1917, there 
were 18 in 1918. Of these, 6 were discharged soldiers, and it may be that war condi¬ 
tions have accelerated the disease amongst those civilian members in whom its exist- 
. ence had not sooner been discovered. 

Sick nursing and visiting. —The more experience we have of the nursing services 
the greater is our admiration of the way in which the ‘ 1 Ranyard” and “Queen’s” 
nurses carry out their duties. No fewer than 156 visits were paid to our own members 
during 1918. These visits occupy sometimes from two to three hours each, and have 
been repeated as often as three times a day. Indeed, in very serious cases a skilled 
nurse would remain with the patient the whole night through. Voluntary service 
of this kind is beyond praise. 

Maternity benefits. —The claims for maternity benefit fell to a remarkable extent 
during the year under report, as the following figures will show: 


Year. 

Claims 

paid. 

Total 

amount. 

Average 
cost per 
member 
per week. 



£ s. 

d. 

1916. 

471 

706 10 

0.62 

1917. 

391 

586 10 

.50 

1918. 

281 

421 10 

.37 


Members continue to avail themselves of the society’s midwifery scheme, with 
satisfactory results. 

Administration expenses. —The total amount spent in administration for the year was 
£61610s. 4d. [$3,000.28, par], which is equivalent to0.54d. [1.1 cent, par] per member 
per week. This is a reduction of 0.19d. [.39 cent, par] on the figures for 1917, which 
worked out at 0.73d. [1.48 cent, par] per member per week. There is thus a surplus 
in the administration account of £75 Is. 3d. [$365.29, par]. But although this result 
is satisfactory, it would not have been attained had not the company relieved the 
society from the increased expenditure on account of war bonuses and allowances 
paid to the staff at hpme and pn active service, 































OPERATIONS OF THE SYSTEM. 


93 


INDUSTRIAL INSURANCE SOCIETY. 

The industrial insurance companies are authorized to act as carriers 
of the national system and they arrange this by creating a separate 
organization for the purpose. One of the largest of the societies of 
this type is the following : 8 

Prudential Approved Society for Men. 

ANNUAL REPORT FOR 1919. 


The committee of management have much pleasure in presenting their report and 
statement of accounts for the year ending December 31, 1919. 

During the year, 126,477 new members were admitted, of whom 107,305 joined the 
society in England, 12,459 in Scotland, 3,127 in Wales, and 3,586 in Ireland. 

The total active membership of the society, including those serving in the forces, 
exceeds 1,600,000. 

The sum of £569,415 10s. 7d. [$2,771,061, par] was paid during the year as sickness 
benefit; £150,177 9s. 3d. [$730,839, par] as disablement benefit; and £149,172 5s. 5d. 
[$725,947, par] as maternity benefit, making, together with subscriptions of £44 9s. 
Id. [$216.34, par] to charitable institutions for the benefit of members, a grand total 
of £868,809 14s. 4d. [$4,228,062, par] paid in benefits during the 53 weeks dealt with 
in the year’s accounts, as compared with £758,389 4s. [$3,690,701, par] in 1918, a period 
of 52 weeks. 

The cost of sickness benefit for the year, after making full allowance for the members 
serving in the navy or army, was only 71 per cent of that allowed for in the original 
estimates of the actuarial advisers of the Government. 

The sum of £1,132,223 7s. 9d. [$5,509,965, par] was invested by the trustees during 


the year. 

The total amount invested by the trustees to the end of the year was £3,507,437 
12s. 2d. [$17,068,945, par], the average rate of interest earned on this sum during 1919 
being £5 4s. 2d. per cent. 

The amount invested in British Government securities is £3,111,630 5s. lid. [$15,- 
142,749, par]. 

In addition to the investments by the trustees the sum of £780,432 [$3,797,972, 
par] has been transferred to the credit of the society in the national health insurance 
fund investment accounts, making a total of £2,564,119 [$12,478,285, par] now stand¬ 
ing to our credit in those accounts. The rate of interest per annum received on this 
sum is 4 per cent. 

The sums paid in benefits during the year 1919 by the four prudential approved 
societies were as follows: Sickness benefit, £1,048,721 4s. lOd. [$5,103,602, par]; 
disablement benefit, £318,897 4s. 8d. [$1,551,913, par]; maternity benefit, £202,314 
8s. 5d. [$984,563, par]; married women’s benefit, £118,088 15s. 7d. [$574,679, par]; 
subscriptions to hospitals, etc., £88 18s. 2d. [$433, par]; making a grand total of £1,- 
688,110 11s. 8d. [$8,215,190, par] (for a period of 53 weeks), as compared with £1,492,- 
207 15s. Id. [$7,261,829, par] during the previous year. 


CASH SUMMARY FOR 1919. 


Receipts. 


Balance brought forward. 

Benefit adjustments in respect of period to Dec. 31, 1918 

From national health insurance fund. 

Interest and dividends. 

Other receipts. 

Total. 


£ 

s. 

d. 

. 133,153 

14 

6 

2, 321 

7 

7 

. 989,379 

8 

2 

. 149,256 

17 

8 

522 

13 

4 

. 1,274,634 

1 

3 


s The National Insurance Gazette, London, June 12, 1920. p. 281. 
104936°—23—Bull. 312-7 














94 


NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


Payments. 


Benefits: £ s. d. 

Sickness benefit. 569,415 10 7 

Disablement benefit. 150,177 9 3 

Maternity benefit. 149,172 5 5 

Subscriptions to hospitals, etc. 44 9 1 


Total. . . 

Administration expenses: 

Paid to Prudential Assurance Co. (Ltd.), 


under agreement. 227, 049 11 10 

Salaries and committee fees. 1,165 6 10 

Medical referees . 4,145 3 9 

Sick visitors. 27,171 17 11 

Arbitration fees and expenses. 57 2 10 

Transfer of securities. 85 4 4 

Incidental expenses. 26 0 7 


£ s. d. 

869,809 14 4 


Total. 259,700 8 1 

Balance carried forward. 146,123 18 10 

Total. 1,274,634 1 3 

INVESTMENT CASH SUMMARY FOR 1919. 

Receipts. 

Balance Dec. 31, 1918. 60 15 1 

From national health insurance fund. 1,132, 592 0 0 

Total. 1,132,652 15 7 

Expenditures. 

Investments. 1,132, 223 7 9 

Balance Dec. 31, 1919. 429 7 10 

Total. 1,132,652 15 7 


chairman’s speech. 


This is the eighth annual meeting of the society and I am pleased to say, as I have 
on previous occasions when making my annual report, that the membership of our 
societies is being well maintained. 

When one realizes the number of societies in existence, and the energy displayed 
in their endeavors to get new members, it speaks well, I think, for our administration 
that there is an increasing desire to join one of the prudential approved societies. 

Last year we added 126,000 new members, which is a considerable increase on the 
previous year when the number was approximately 90,000. 

This large annual influx of members does not necessarily mean a net increase in our 
membership, for, as you are aware, there is in every year a big natural wastage due to 
deaths and passing out of insurance of members and to other causes. 

It is now more than 18 months since the armistice was signed, and although we try 
to forget so far as we possibly can the ravages of the Great War, yet its effects are with 
us from day to day, and present themselves whenever we deal with matters affecting 
the population as a whole. 

At the end of 1919, 236,000 of our members were either still in His Majesty’s forces 
or had not notified us of their discharge, as you know, the remaining members of the 
temporary army were demobilized in April last, so that from this special point of 
view we are now only concerned with those who have permanently adopted the navy 
or army as a profession. 

Sickness experience .—The sickness experience of those members who have served 
probably throws a greater burden upon the societies than would have been the case 
had they continued to follow their ordinary civil vocations. It is, therefore, more 
than gratifying to know that the cost of sickness benefit for the year was only 71 per 
cent of that allowed for in the original estimates of the actuarial advisers to the Govern¬ 
ment. 

The accounts show that the amount paid during the year in sickness and disable¬ 
ment benefits was £719,592 19s. lOd. [$3,501,899, par]. 

As a result of the influenza epidemic at the commencement of the year the amount 
paid in these benefits during the first six months was £95,000 [$462,318, par] in excess 































OPERATIONS OF THE SYSTEM. 


95 


of that paid during the corresponding period of 1918, but in the second six months of 
1919 the amount so paid was <£23,000 [$111,930, par] less than in the second half of 1918. 

Maternity benefit. —The experience of the society as regards maternity benefit 
presents some interesting features. The total amount paid for this benefit was 
£149,172 [$725,945.54, par], which is nearly £23,500 [$114,362.75, par] in excess of the 
sum so paid during 1918. This increase is almost entirely due to the last quarter of 
the year, the average number of maternity claims per week having been approximately 
1,600 between January 1 and August 30; 1,750 during September; 2,400 during Octo¬ 
ber and November, and nearly 3,000 during December. The experience of De¬ 
cember—that is nearly 3,000 maternity claims per week—is twice as heavy as that of 
December, 1918, and it will interest you to know that this large number has been 
maintained so far this year. This, while expensive to the society, is highly satis¬ 
factory from the national point of view. 

Ten million two hundred and fifty thousand pounds paid in benefits. —As showing the 
magnitude of the work of the prudential approved societies, I may perhaps mention 
that the total amount paid by the four societies in benefits from January, 1913, to the 
end of 1919, a period of seven years, was approximately £10,250,000 [$49,881,625, par]. 

The accounts in your hands include an investment cash summary, which states 
the amount invested during the year, but does not show the advantages derived by 
the society from the knowledge and skill of the trustees in connection with invest¬ 
ments. 

As indicated in the report, the amount invested on behalf of this society by the 
trustees is slightly over £3,500,000 [$17,032,750, par], yielding an average rate of 
interest of £5 4s. 2d. per cent free of income tax, whereas the rate to be employed 
in the valuation of our liabilities is only 3 per cent. 

The trustees for this society act as trustees for the other three prudential approved 
societies, and on behalf of the four societies have invested close on £5,500,000 
[$26,765,750, par]. 

Since 1914 the average rate of interest earned on the total investments increased by 
more than £1 per cent, giving, as stated above, a yield of £5 4s. 2d. free of income tax. 

ASSOCIATION OF SMALL SOCIETIES. 

The operations of the insurance require that the very small socie¬ 
ties shall be joined into associations as a measure of reinsurance. 
As an illustration of a small association of this kind, the following is 
given : 9 

Sussex National Insurance Association. —The annual report of the County of Sussex 
National Insurance Association has just been issued. It is stated that the associa¬ 
tion has now been officially approved by the commissioners for national health to 
carry on the duties involved under the national health insurance act, 1918. With 
one exception, the returns for last year have been sent in by the associated societies, 
and the results show a small increase in the total benefits paid out as compared with 
the previous year. There has been a reduction in the total sickness benefits (£1,621) 
[$7,888.60, par] of £40 [$194.66, par], but an increase in the disablement benefits from 
£474 [$2,306.72, par] in 1917 to £545 [$2,652.24, par] in 1918. Maternity benefits 
decreased from £253 [$1,231.22, par] to £240 [$1,167.96, par]. The net result is a small 
increase in benefit payments as a whole of nearly £18 [$87.60, par]. The number of 
societies in the association on December 31, 1918, was 35, with a total membership 
of 4,933, excluding members over 70 years of age. The total administration expenses 
of the associated societies amount to £716 [$3,484, par], and is under the official 

allowance. . . . ,, . 

Mr. Cautley, K. C., M. P., president of the association, in the course of his report, 
said: “Our societies are perfectly solvent, and will, I am convinced, show considerable 
surpluses. The valuation by the Government auditors is now being made. I am 
confident that we shall be able to pay a substantially larger sick benefit than the 
statutory 10s. [$2.43 par]. This being so, the working men of Sussex in this associa¬ 
tion have a most valuable property and one entirely their own. Every penny saved 
goes to themselves. There are no shareholders or other persons to be benefited ex¬ 
cept themselves. I can not believe that if these facts were known to the Sussex 
workers they would let such a valuable property go. I regret that, so far, I have not 
heard of the suggestion of the formation of juvenile branches, which I made at the 
last annual meeting being carried out.” 


» The National Insurance Gazette, London, Oct. 11,1919, p. 450. 




APPENDIX.—BIBLIOGRAPHY ON NATIONAL HEALTH INSURANCE IN 

GREAT BRITAIN. 


Abbott, Edith. ‘‘The British health insurance system/' in Report, recommenda¬ 
tions and dissenting opinions by the Ohio Health and Old Age Insurance Commission. 
Columbus, January, 1919. Also, in Report of the Health Insurance Commission 
of the State of Illinois. Springfield, May 1, 1919. 

American Association for Labor Legislation. Health insurance. American Labor 
Legislation Review, June, 1916, v. 6. [Later issues contain extensive studies on 
the British system.] 

Annan, William. The Duties of Employers under the National Insurance Act, 1911. 
Edinburgh and London [1912]. 

Ashley, Annie. The Social Policy of Bismarck. London, New York [etc.], 1912. 
British Medical Association: 

Insurance acts committee. Interim report on the future of the insurance acts. 
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-Report on the revision of the conditions of service under the national health 

insurance acts and possible extensions of service. London, 1919. 

“British social insurance and the doctors’ union,” in Survey, December 14, 1912. 
Carr, A. S. Comyns (ed.) W. H. Stuart Garnett, and J. H. Taylor. National Insurance. 
4th ed. London, 1913. 

Collier, Sir John. Malingering and Feigned Sickness. New York, 1913. 

Dawes, James A. National Health Insurance: Part 1 of the national insurance act, 
1911, indexed and summarized. London, 1912. 

Dawson, William H. “ Social insurance in England and Germany—a comparison, ” 
in Fortnightly Review, August, 1912. 

Evans, Laming W. The National Insurance Bill. Summary. 4th ed. West¬ 
minster, 1911. 

Fabian Society: 

Executive co mmi ttee. The Insurance Bill and the Workers. London, 1911. 
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supplement. 

Fischer, Alfons. Die Mutterschaftsversicherung in den europaischen Landem. 
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Frankel, Lee K. (and Miles M. Dawson, with the cooperation of Louis I. Dublin). 

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Gadd, Henry W. A Guide to the National Insurance Act, 1911. London, 1912. 
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mark. London, 1912. 

Great Britain: 

Admiralty. National insurance instructions, 1914. London, 1914. 

Board of Trade. Industrial life assurance committee. Report on the business 
of industrial assurance companies and collecting societies. London, 1920. 
[Cmd. 614.] 


96 


APPENDIX—BIBLIOGRAPHY. 


97 


Great Britain—Continued. 

Chancellor of the Exchequer: 

National health insurance. Statements as to the administration of medical 
benefit and correspondence thereon between the Chancellor of the Ex¬ 
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National insurance bill. Actuarial report on the position of persons in the 
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Copy of Memorandum explanatory of the principal amendments which it is 
proposed to incorporate in the National Insurance Bill. London, 1911. 
[Cd. 5930.] 

Replies to letters addressed to the Chancellor of the Exchequer. London, 
1911. [Cd. 5733.] 

Further replies to letters addressed to the Chancellor of the Exchequer (in 
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[Cd. 5885.] 

Reports of deputations. London, 1911. [Cd. 5869.] 

Reports of the actuaries as to the rate of sickness prevailing in the agricultural 
districts of Scotland. London [1911]. [Cd. 5966.] 

National Insurance Bill and Buntingford Union Association. [Actuarial.] 
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Departmental committee on approved society finance and administration. 

Interim report . . . and correspondence thereon. London, 1916. [Cd. 8251.] 
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London, 1916. [H. of C. Reports and Papers.] 

Government Actuary. National health insurance. Interim report upon the 
valuation of the assets and liabilities of approved societies as at 31st December, 
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Interdepartmental committee on appointment of audit staff (national insurance 
act, 1911, Pt. I). Reports. London, 1912. [Cds. 6232, 6243.] 
Interdepartmental committee on outdoor staff (national insurance act, 1911, Pt. I). 
Report. London, 1912. [Cd. 6231.] 

Interdepartmental committee on payment through the post of benefits under the 
national insurance act. National insurance acts, 1911-1913. Report. London, 
1914. [Cd. 7245.] 

Interdepartmental committees under the Crown as affected by Part I of the 
national insurance act, 1911. National insurance act, 1911, Pt. I. First report. 
London, 1912. [Cd. 6234, 6315.] 

Laws, statutes, etc.: 

Married women’s special benefits regulations, 1912, dated September 19, 1912 
(provisional). [H. C. 309, 1912.] Draft dated September 20, 1912. 

Married women’s transfer value regulations, 1914, dated May 22, 1914. 
[H. C. 261, 1914.] 

National health insurance. Statutory rules and orders issued during 1912, 
with an index to the statutory powers and rules and orders in force on 31st 
December, 1912. . . . London, 1913. 

National health insurance acts, 1911-1920. Summary of the provisions of the 
national health insurance acts, 1911-1920, for the information of members 
of approved societies. London, 1920. 

National insurance act, full text (with index). [Glasgow, 1911.] (Issued 
with the Glasgow Herald of December 21, 1911.) 

National insurance act, 1911. With introduction and notes, by J. A. Lovat- 
Fraser. . . . London, 1912. 


98 NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 

Great Britain—Continued. 

Laws, statutes, etc.—Concluded. 

National insurance act, 1911. Index to the health insurance provisions of 
the act. . . . London, 1912. [Cd. 6468.] 

-Treatise on the scheme of national health insurance and insurance 

against unemployment created by that act, by Orme Clarke. London 
[etc.], 1912. 

National health insurance bill. [London, 1917.] [H. of L. Papers and 
Bills, 119.] 

-Actuarial report on proposed Government amendments to clause 36 

(special provision with regard to persons in the naval and military serv¬ 
ice of the Crown). London, 1911. [Cd. 5943.] 

-Copy of a memorandum explanatory of the bill as passed by the House 

of Commons so far as relates to national health insurance. London, 
1911. [Cd. 5995.] 

-Copy of clause 36, as amended, of the national insurance bill: Special 

provisions with regard to persons in the naval and military service of the 
Crown. London, 1911. [Cd. 5941.] 

-Copy of memorandum explanatory of the bill, Treasury Chambers, 8 

May, 1911, D. Lloyd-George. London, 1911. [H. C. 147.] 

-Copy of memorandum on sickness and invalidity insurance in Germany. 

London, 1911. [Cd. 5678.] 

-Copy of the national insurance bill, showing the difference between 

the bill as introduced in the House of Commons and as passed by that 
house . . . London, 1911. [Cd. 5989.] 

-Mercantile marine. Copy of memorandum explanatory of the amend¬ 
ments which it is proposed to incorporate in the national insurance bill in 
regard to seamen in the mercantile marine. London, 1911. [Cd. 5942.] 

National insurance valuation regulations, 1919. Statutory rules and orders, 

1919. No. 1119. London, 1919. 

The national insurance bill; together with official explanatory memoranda 
on its provisions. Report of Mr. Lloyd-George’s speech on the introduc¬ 
tion of the measure, and notes, by the editors of the Poor-law Officers’ 
Journal. London, 1911. 

The law of national insurance, with introduction and notes, by Edmond 
Browne . . . and H. Kingsley Wood ... 2d ed. London, 1912. 

The law relating to national insurance. With an explanatory introduction, 
the text of the national insurance act, 1911, annotated, and appendices 
containing regulations, rules, orders, etc., issued by the insurance com¬ 
missioners and the Board of Trade, actuaries’ memoranda, etc., by J. H. 
Watts . . . London, 1913. 

The statutes relating to national health insurance and regulations affecting 
the administration of approved societies. London, 1918. 

Local Government Board: 

National insurance bill. Extracts from reports upon sanitary administration 
in certain urban and rural districts . . . London, 1911. [Cd. 5984.] 

Sanatoria. List of approved sanatoria, October 1, 1914. London [1914]. 

-List of approved sanatoria and other residential institutions. London 

1918. 

Ministry of Health: 

First annual report, 1919-20. Part IV—Administration of national health 
insurance (1917 to 31st March, 1920).—Welsh Board of Health. London 

1920. [Cd. 913.] 

Annual report of the chief medical officer on the state of the public health for 
the year 1920. London, 1921. [Cmd. 1397.] 


APPENDIX—BIBLIOGRAPHY. 


99 


Great Britain—Continued. 

Ministry of Health—Concluded. 

Memorandum by the Government actuary on the Washington Draft Conven¬ 
tion concerning the employment of women before and after childbirth. 
London, 1921. [Cmd. 1293.] 

Model rules for an approved society, relating to business under the national 
insurance (health) acts, 1911-1919, to form Part II of the existing rules of a 
society approved as a whole. London, 1919. 

Model rules for an approved society, to be added to the existing Part I rules 
when the necessary provision is not already contained in those rules. 
London, 1919. 

National health insurance bill, 1920. Report by the Government actuary 
upon the financial provisions of the bill. London, 1920. [Cd. 612!] 

National health insurance (medical benefit) regulations, 1920, made under the 
national insurance (health) acts, 1911 to 1919. London, 1920. 

Sanatoria. List of approved sanatoria and other residential institutions. 
London, 1919. 

Second annual report, 1920-21. London, 1921. [Cd. 1446.] 

Welsh Consultative Council of Medical and Allied Services in Wales. First 
report. London, 1920. [Cd. 703.] 

Ministry of Reconstruction. Memorandum on the ministries of health bill, 1918. 

London, 1918. [Cd. 9211.] 

National Health Insurance Commission (England): 

Constitution of insurance committees, 1913. London, 1913. [Cd. 6831.] 

Employed married women, regulations, 1914, dated May 28, 1914. [H. C. 
263, 1914.] 

Handbook to the administration of sickness and maternity benefits by ap¬ 
proved societies. Provisional issue, January 13 to July 14, 1913. 

How rates of remuneration affect health insurance contributions. Official 
Explanatory Leaflet No. 18. 2d ed. London, 1914. 

Memoranda of decisions under section 66 of the national insurance act, 1911 
(with index). April, 1913. London, 1913. 

Memorandum on the special measures taken in relation to the supply of drugs 
and other medical stores during the war. London, 1919. [Cd. 183.] 

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health insurance (deposit contributors benefits) order, 1913 . . . London, 
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-Report by the chief inspector to the National Health Insurance Com¬ 
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persons became deposit contributors . . . London, 1913. [Cd. 7034.] 

National insurance acts. Handbook for the use of approved societies (English 
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national insurance act, 1911, and section 27 of the national insurance act, 
1913. . . . London, 1915. [Cds. 7810, 8040.] 


100 NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 


Great Britain—Continued. 

National Health Insurance Commission (Ireland): 

Medical benefits committee. National insurance act, 1911—medical benefit, 
Ireland. Report of the committee appointed to consider the extension 
of medical benefit under the national insurance act to Ireland. . . . Lon¬ 
don, Dublin, 1913. [Cd. 6963.] Appendices to the Report. [Cd. 7039.] 

National Health insurance act, 1918. Supplement to the Handbook for the 
use of approved societies having members resident in Ireland. Dublin, 
1918. 

Report for 1912 on the administration in Ireland of the national insurance act, 
Pt. I. (Health insurance.). . . London, 1913. 

Report on the administration of national health insurance in Ireland during 
the period November, 1917, to 31st March, 1920. Dublin, 1921. [Cmd. 
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National Health Insurance Commission (Scotland): 

National health insurance. Handbook for the use of insurance committees 
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National insurance act, 1911. Handbook to the administration of sickness 
and maternity benefits by approval societies in Scotland. London, Edin¬ 
burgh, 1913. 

National insurance acts. Handbook for the use of approved societies (Scot¬ 
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Report for 1912 on the administration in Scotland of the national insurance 
act, Pt. I. (Health insurance.) . . . London, 1913. 

Statement showing the number of insured persons, the number of members of 
each approved society, and the number of deposit contributors, in the 
area of each insurance committee in Scotland. . . . London, 1913. [Cd. 
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National Health Insurance Commission (Wales): 

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ed.). (Provisional issue rev. to August, 1915.) Edinburgh, 1916. 

Report for 1912 on the administration in Wales of the national insurance act, 
Pt. I. (Health insurance.) . . . London, 1913. 

National Health Insurance Joint Committee: 

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Committee on national insurance act (medicines). National insurance act, 
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[Cd. 6853-6854.] 

Committee on sickness benefit claims under national insurance act. National 
health insurance. Reports [and Appendix. . . . ] ... London, 1914. 

[Cd. 7687-7691.] 

Medical benefit under the German sickness insurance legislation . . . London, 
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Medical research committee. . . . Bacteriological studies in the pajhology 
and preventive control of cerebrospinal fever among the forces during 
1915 and 1916 . . . [London, 1917.] (Special report series, No. 3.) 

-Interim report on the work in connection with the war at present 

undertaken by the medical research committee. . . . London, 1915. 
[Cd. 7922.] 


APPENDIX-BIBLIOGRAPHY. 


101 


Great Britain—Continued. 

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- Reports upon investigations in the United Kingdom of dysentery cases 

received from the eastern Mediterranean. . . . London, 1917. 

- Specialad visory committee. . . . Report upon bacteriological studies 

of cerebrospinal fever during the epidemic of 1915. [London, 1916.] 
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-Notes explanatory of the national health insurance bill, 1917, as passed 

by the House of Commons. London, 1917. [Cd. 8896.] 

National insurance act, 1911. List [s] of approved societies. . . . London, 
1912. [Cd. 6238, 6284.] 

-(B.) Model rules for an approved society with male members only. 

. . . London, 1912. 

-Rev. ed. London, 1912. 

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benefits under section 13, together with an actuarial memorandum. . . . 
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general objects of the bill. . . . London, 1913. [Cd. 6914.] 

National insurance acts, 1911 to 1913. National health insurance fund 
accounts for the period 12th January to 31st December, 1914. London, 
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National insurance (health) acts, 1911 to 1918. Return as to the administra¬ 
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for the information of members of approved societies. London, 1918. 
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accounts. Appendix. Approved societies and insurance committee8 , 
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National health insurance acts, 1911 to 1920. List of approved societies oper¬ 
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Scotland, Ireland, and Wales, respectively. London, 1920. 

Outworkers committee. . . . Report of the committee appointed to consider 
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outworkers. . . . Report [with evidence and appendices]. London, 1912. 
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Report on approved societies’ administration allowance. London, 1921. 
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102 NATIONAL HEALTH INSURANCE IN GREAT BRITAIN. 

Great Britain—Concluded. 

Parliament: 

House of commons. Reprint from the Parliamentary Debates of all Ques¬ 
tions and Answers in the House of Commons Relating to the National Insur¬ 
ance Act, 1911. February 14 to August 7, 1912. 

-Reprint from the Parliamentary Debates of all Questions and Answers 

in the House of Commons Relating to National Health Insurance. October 
7 , 1912, to March 7, 1913. 

-Standing committee on bills, A. Report on the national health insurance 

bill with the proceedings of the committee. London, 1917. [H. of C. 
Reports and Papers 164.] 

Registry of Friendly Societies: 

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thereon; and monetary tables (together with introductory report) reprinted 
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returns made by registered friendly societies for the years 1856 to 1880, 
inclusive, together with a report, ... by William Sutton . . . London, 
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Scotland: 

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health insurance in Scotland during the years 1917-1919. London, 1920. 
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Treasury: 

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disablement, etc., embodied in the national insurance bill, 1911. London 
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Halsey, Olga S. “Compulsory health insurance in Great Britain,” in American 
Labor Legislation Review, June, 1916. 

Hardy, George F. and Frank B. Wyatt. “ Report of the actuaries in relation to the 
scheme of insurance against sickness, disablement, etc., embodied in the national 
insurance bill, 1911,” in Institute of Actuaries Journal, July, 1911. 

Harris, Henry J. ‘ ‘Maternity benefit systems in certain foreign countries. ’ ’ United 

States Children’s Bureau. Publication No. 57. Washington, 1919. 

Hayes, Carlton H. “National insurance,” in his British Social Politics. Boston 
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Hoffman, Frederick L.: 

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Federation, January 30, 1920. [New York, 1920.] 


APPENDIX—BIBLIOGRAPHY. 


103 


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1st, Paris, 1889. 

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Jenny, Oskar H. Das Englische Hulfskassenwesen In Neuester Zeit. . . . Bern, 
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Pope, Samuel. . . . Married women outworkers. Report on the objections raised 
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o 





(Continued from second page of cover,) 

*Bul. 91, November, 1910, Review of labor legislation of 1910. ^ ; 

1911, Conditions of employment in the iron and steel industry in the United States (S. Doc. 110, 
62d Cong., 1st sess.). 

*VoL IV, Accidents and accident prevention. 

*Bul. 92, January, 1911: ;, 

Workingmen’s compensation and insurance: Laws and bills, 1911. t ! ; 

Resolutions of the sixth delegates’ meeting of the International Association for Labor Legisla- 
tion. ,j~ ■ ■■ '» c ; 

*Bul. 96, September, 1911, Workmen’s insurance code of July 19,1911, of Germany. yc>.. ; --y 
*Bul. 97, November, 1911, Review of labor legislation of 1911. 

A list of the bulletins in the series “Workmen’s Insurance and Compensationis as 
follows: >’ r ’• \. ■- : - 

Bui. 101, July, 1912, Care of tuberculous wage earners in Germany. 

Bui. 102, July, 1912, British national insurance act, 19U-. 

Bui. 103, August, 1912, Sickness and accident insurance law of Switzerland. 

Bui. 107, September, 1912, Law relating to insurance of salaned employees in Germany. 

*Bul. 126, December, 1913, Workmen’s compensation laws of the United States and foreign countries. 
*Bul. 155, September, 1914, Compensation for accidents to employees of the United States..- 0 
*BuI. 1S5, October, 1915, Compensation legislation of 1914 and 1915. : 

Bui. 203, January, 1917, Workmen’s compensation laws of the United States and foreign countries.. 
Bui. 210, May, 1917, Proceedings of the third annual meeting of the International Association of 
Industrial Accident Boards and Commissions. ->. 'y >/' i '' 

Bui. 212, June, 1917, Proceedings of the Conference on Social Insurance called by the International 
Association of Industrial Accident Boards and Commissions, December s to 9, 1916, Washing¬ 
ton, D. C. - , v 

Bui. 217, December, 1917, Effect of workmen’s compensation laws in diminishing the necessity 
of industrial employment of women and children. 

‘ Bui. 240, May, 1918, Comparison of workmen’s compensation laws of the United States up to 
December 31,1917. 

Bui. 243, October, 1918, Workmen’s compensation legislation of the United States and foreign 

countries, July, 1918. ' J.-’ "-.' •■-a 

Bui. 248, March, 1919, Proceedings of the fourth annual meeting of the International Association 
of Industrial Accident Boards and Commissions,;*y A,rif vyy %>•'.. : y; 

Bui. 264, June, 1919, Proceedings of fifth annual meeting of the International Association of Indus¬ 
trial Accident Boards and Commissions. ..: V- 

Bui. 272, January, 1921, Workmen’s compensation legislation of the United States and Canada, 

.1919. - ° : 

Bui. 273, August, 1920, Proceedings of the sixth annual meeting of the International Association 
of Industrial Accident Boards and Commissions. " yf 

Bui. 275, September, 1920, Comparison of workmen’s compensation laws of the United States and 

Canada. 1 ir.-.ti- '/ • rv-f ^ 

Bui. 281, June, 1921, Proceedings of the seventh annual meeting of the International Association 

of Industrial Accident Boards and Commissions ; >- 
Bui. 301, April, 1922, Comparison of workmen’s compensation insurance and administration. 

Bui. 304, August, 1922, Proceedings of the eighth annual meeting of the International Associa¬ 
tion of Industrial Accident Boards and Commissions. 

The following bulletins, published since July 1, 1912, but \not included in the series 
« Workmen’s Insurance and Compensation,” also contain important material relating to the 
subject: / .'yV ' 

Bui. Ill, December, 1912, Labor legislation of 1912. 

1913, Compensation for injuries to employees of the United States arising from accidents occurring 
between August 1,1908, and June 30,1911. 

Report of operations under the act of May 30, 1908. 

*Bul. 112, March, 1913, Decisions of courts and opinions affecting labor, 1912. 

Bui. 152, May, 1914, Decisions of courts and opinions affecting labor, 1913. 

Bui. 166, December, 1914, Labor legislation of 1914. 

Bui. 169, May, 1915, Decisions of courts affecting labor, 1914. 

Bui. 189,' May, 1916, Decisions of courts affecting labor, 191V. 

Bui. 211, January, 1917, Labor laws and their administration in the Pacific States. p.. .v ‘ 

Bui. 224, September, 1917, Decisions of courts affecting labor, 1916. >.y;f 

Bui. 246, September, 1918, Decisions of courts affecting labor, 1917. 

Bui. 258, December, 1919, Decisions of courts and opinions affecting labor, 1918. 

Bui. 290, January, 1922, Decisions of courts and opinions affecting labor, 1919-20. 

Bui. 309, Decisions of courts and opinions affecting labor, 1921. 


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